{"id":12922,"date":"2023-04-09T01:42:38","date_gmt":"2023-04-09T01:42:38","guid":{"rendered":"https:\/\/www.goodacademic.com\/blog\/questions\/develop-a-soap-note-i-need-it-to-be-for-a-teenager-age-can-be-between-13-17-dealing-with-pulmonary\/"},"modified":"2023-04-09T01:42:38","modified_gmt":"2023-04-09T01:42:38","slug":"develop-a-soap-note-i-need-it-to-be-for-a-teenager-age-can-be-between-13-17-dealing-with-pulmonary","status":"publish","type":"questions","link":"https:\/\/www.goodacademic.com\/blog\/questions\/develop-a-soap-note-i-need-it-to-be-for-a-teenager-age-can-be-between-13-17-dealing-with-pulmonary\/","title":{"rendered":"Develop a SOAP note (I need it to be for a teenager age can be between 13-17 dealing with pulmonary)"},"content":{"rendered":"

I do not of course need the recording because I can do that on my own. But everything else I would need.<\/p>\n

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Assignment Prompt:\n<\/div>\n
Signature Assignment Description\/Directions: Develop a SOAP note and accompanying oral presentation. Choose a memorable, interesting, or challenging patient encounter during this clinical rotation that you have not previously presented to your class or submitted for a SOAP note. Do not use simple cases such as URI or UTI symptoms, ear pain, sore throat, follow-ups, or runny nose. Ask your instructor if you are in doubt whether or not your case is challenging or interesting.\n<\/div>\n
Directions:\n<\/div>\n
Submit a written SOAP note for this case, with an assessment and plan that demonstrate critical thinking skills and application of evidence based practice.\n<\/div>\n
Support your clinical decision making with at least two (2) peer-reviewed references other than required course textbooks.\n<\/div>\n
After writing your SOAP note, record an oral presentation to accompany the note to describe the case to your instructor and classmates.\n<\/div>\n
Engage your audience and explain why the case was a meaningful learning opportunity. Spend more time on the sections discussing why the case was meaningful, your critical thinking process, and your holistic approach and caring science, since the written portion will elaborate on the medical aspects of the case. Keep the oral presentation of the facts of the case brief.\n<\/div>\n
Explain which resources you used and which portions of the history or physical led you to the chosen diagnosis and include the evidence that supported your decision making and treatment plan.\n<\/div>\n
In the presentation, include how you incorporated a holistic approach and how you applied one of Jean Watson\u2019s ten carative factors into your care of this patient.\n<\/div>\n
Include the following in your oral presentation:\n<\/div>\n
Introduction\n<\/div>\n
Your name\n<\/div>\n
Your clinical site\/type and location\n<\/div>\n
Brief description of the case (ID, CC, brief HPI)\n<\/div>\n
Describe why the case was meaningful, memorable, interesting, or challenging to you\n<\/div>\n
Presentation of case (brief)\n<\/div>\n
Subjective information\n<\/div>\n
ID, CC, HPI\n<\/div>\n
PMH, SH, FH\n<\/div>\n
ROS\n<\/div>\n
Objective Information\n<\/div>\n
Vital Signs (if all are normal, it is ok to say so)\n<\/div>\n
Physical Exam (only describe pertinent findings, otherwise it is ok to say unremarkable)\n<\/div>\n
Pertinent recent diagnostics (if available)\n<\/div>\n
Assessment\n<\/div>\n
Differentials you considered\n<\/div>\n
Resources used to narrow the differentials\n<\/div>\n
Your critical thinking process\n<\/div>\n
Final diagnosis and any secondary diagnoses\n<\/div>\n
Plan\n<\/div>\n
Diagnostic, therapeutic, educational and follow up components\n<\/div>\n
Application of evidence based practice\n<\/div>\n
Why did you select the chosen therapy\/referral\/diagnostic approach\n<\/div>\n
What support is there for your plan\n<\/div>\n
What alternatives were considered\n<\/div>\n
Holistic Approach and Caring Science\n<\/div>\n
Provide examples of how you collaborated or could have collaborated with the patient, family, or other members of the care team to achieve better healthcare outcomes. Include cultural considerations.\n<\/div>\n
Which of Jean Watson\u2019s Caring Processes were considered with this patient?\n<\/div>\n
In what ways was your care of this patient representative of a holistic approach?<\/div>\n
\n<\/div>\n
\n<\/div>\n
\n<\/div>\n
\n<\/div>\n","protected":false},"excerpt":{"rendered":"

I do not of course need the recording because I can do that on my own. But everything else I would need. Assignment Prompt: Signature Assignment Description\/Directions: Develop a SOAP note and accompanying oral presentation. Choose a memorable, interesting, or challenging patient encounter during this clinical rotation that you have not previously presented to your […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"closed","template":"","meta":[],"disciplines":[190],"paper_types":[],"tagged":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/questions\/12922"}],"collection":[{"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/questions"}],"about":[{"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/types\/questions"}],"author":[{"embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/comments?post=12922"}],"version-history":[{"count":0,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/questions\/12922\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/media?parent=12922"}],"wp:term":[{"taxonomy":"disciplines","embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/disciplines?post=12922"},{"taxonomy":"paper_types","embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/paper_types?post=12922"},{"taxonomy":"tagged","embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/tagged?post=12922"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}