NSG 6340 4 Assignment SOAP Note and CORE Entries

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NSG 6340 4 Assignment SOAP Note and CORE Entries

NSG 6340 4 Assignment SOAP Note and CORE Entries

CORE Entries and SOAP Notes

You must enter your patient encounters into CORE once a week. Your professors will double-check that you’re seeing the proper amount and mix of patients for a positive learning experience. You must also use this template to include a minimum of one complete SOAP note. The SOAP note should be connected to this week’s topic, and it should be submitted to the Submissions Area once completed. Make sure to mention the CORE reference number while submitting your note.

Submission Details:

By the due date assigned enter your patient
encounters into CORE and complete at least one SOAP note in the template
provided.

Name your SOAP note document
SU_NSG6340_W4_SOAPLastName_FirstInitial.doc.

Include the reference number from CORE in
your document.

Submit your document to the Submissions
Area by the due date assigned

What are the Four Parts of a SOAP Note?

The four parts of a SOAP note are the same as its abbreviation. All four parts are designed to help improve evaluations and standardize documentation:

  • Subjective – What the patient tells you
  • Objective – What you see
  • Assessment – What you think is going on
  • Plan – What you will do about it

How to Write a SOAP Note Following the SOAP Note Format?

Writing in a SOAP note format—Subjective, Objective, Assessment, Plan—allows healthcare practitioners to conduct clear and concise documentation of patient information. This method of documentation helps the involved practitioner get a better overview and understanding of the patient’s concerns and needs.

Below is a walkthrough of how you can effectively write a SOAP note following the SOAP note format:

Subjective – What the Patient Tells you

NSG 6340 4 Assignment SOAP Note and CORE Entries

NSG 6340 4 Assignment SOAP Note and CORE Entries

This section refers to information verbally expressed by the patient. Take note of the patient ’s complete statement and enclose it in quotes. Recording patient history such as medical history, surgical history, and social history should also be indicated as it can be helpful in determining or narrowing down the possible causes.

SOAP Note Example:

Subjective: Patient states: “My throat is sore. My body hurts and I have a fever. This has been going on for 4 days already.”

Patient is a 23-year-old female. Prior to this, patient says she had a common cold and whooping cough then progressed to the current symptoms.

Objective – What You See

This section consists of observations made by the clinician. Do a physical observation of the patient’s general appearance and also take account of the vital signs (i.e temperature, blood pressure etc). If special tests were conducted, the results should be indicated in this section. Using the previous example, we can write the objective like this:

SOAP Note Example:

Objective: Vital signs represent a temperature of 39°, BP of 130/80. Patient displays rashes, swollen lymph nodes and red throat with white patches.

Assessment – What You Think is Going on

This section tells the diagnosis or what condition the patient has. The assessment is based on the findings indicated in the subjective and objective section. This section can also include diagnostic tests ordered (i.e x-rays, blood work) and referral to other specialists. Using the same example, the assessment would look like this:

SOAP Note Example:

Assessment: This is a 23-year-old female with a history of common cold and whooping cough and reporting for a sore throat, fever, and fatigue. Clinical examination suggests bacterial pharyngitis due to swollen lymph nodes and the presence of white patches on the throat.

  1. Pharyngitis
  2. High Fever (caused by pharyngitis)
  3. Fatigue

Plan – What You Will Do About It

This section addresses the patient’s problem identified in the assessment section. Elaborate on the treatment plan by indicating medication, therapies, and surgeries needed. This section can also include patient education such

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as lifestyle changes (i.e food restrictions, no extreme sports etc). Additional tests and follow up consultations can also be indicated. With the same example, the plan section can be written like this:

SOAP Note Example:

Plan:

  1. Acetaminophen – take every 6 hours x 5 days
  2. Penicillin (500mg) – once a day for 5 days
    No labs or consults. Follow up after 5 days if symptoms persist or worsen. Drink plenty of water and intake Vitamin C

SOAP Note Example

What is iAuditor and How Can I Use it for SOAP Notes?

Healthcare professionals can use iAuditor, the world’s #1 inspection software, to digitally gather SOAP notes and improve the quality and continuity of patient care.

  • Create SOAP notes in digital format and easily update and share with teammates
  • Collect photo evidence for a more informative and descriptive patient record.
  • Save completed SOAP reports in a safe cloud storage
  • Easily share your findings with other healthcare clinicians and avoid losing track of patient records by securely saving it in the cloud using iAuditor
  • Facilitate digital sign-offs to verify acknowledgment of SOAP assessment

To help you get started we have created SOAP note templates you can download and customize for free.

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