Reference no: EM133824583

Homework

For this homework, students will create a SOAP note reflective of the patient care experience in the clinical setting under the supervision of the clinical preceptor in the role of the clinical provider. This homework will evaluate the student clinical reasoning skills, interviewing skills, physical exam skills, selection of diagnostic testing, differential diagnosis, pharmaceutical and non-pharmaceutical treatment, patient education, and follow-up plan.

Students must develop the clinical skills and knowledge required for safe practice and deliver best patient outcomes upon graduation. SOAP notes should be used to document each patient seen in the clinical setting. Clear, concise, and thorough documentation is required for continuity of care, safe practice, appropriate reimbursement, and prudent risk management.

When developing the SOAP note, students should use the homework criteria below and the ACON SOAP Note Template found in this weeks' module. Students should include complete subjective and objective information to support the assessment and plan. The plan must include diagnostic and treatment measures, patient education, and follow-up.

Keep the following points in mind:

I. Use the ACON SOAP Note template as a guide
II. Identify and collect relevant subjective and objective data
III. Use proper medical terminology and documentation
IV. Use proper ICD-10 coding and Current Procedural Terminology (CPT) E/M coding
V. Identify any cultural/religious/racial/gender influences on care

Homework Criteria:

Students will complete a SOAP note and include the following:

I. Subjective findings

i. Chief complaint (CC)
ii. History of present illness (HPI)

II. Use mnemonic: onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and severity (OLDCARTS)

III. Past medical/surgical/social/family history

IV. Medications

i. Allergies, prescription/over the counter (OTC)/herbal medications
ii. Comprehensive review of systems (ROS)

V. Objective findings

i. Appropriate physical examination based on subjective findings
ii. Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit
iii. Screening tools and positive and negative results

VI. Assessment

i. Correct primary diagnosis
ii. Correct differential diagnoses
iii. Correct ICD-10/Current Procedural Terminology (CPT) codes

VII. Plan

i. Identify and orders correct diagnostics, prescriptions, referrals, and follow-up plan
ii. Patient education relative to treatment plan.
iii. Correctly written out a prescription for one medication prescribed for the patient.

VIII. If a medication not prescribed, write out a prescription for a medication that might be prescribed for a similar patient

IX. Include two current evidence-based guidelines and/or peer-reviewed scholarly journals to support patient education and treatment plan. The student can pick one evidence-based guideline and one scholarly article. References should be from scholarly peer-reviewed journals (check Ulrich's Periodical Directory) and be less than five years old.