soap note nursing
Select a patient whom you examined during the last three weeks. With this patient in mind, address the
following in a SOAP Note:
?Subjective: What details did the patient provide regarding her personal and medical history?
?Objective: What observations did you make during the physical assessment?
?Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List
them from highest priority to lowest priority. What was your primary diagnosis and why?
?Plan: What was your plan for diagnostics and primary diagnos??????is? What was your plan for
treatment and management, including alternative therapies? Include pharmacologic and
nonpharmacologic treatments, alternative therapies, and follow?up parameters, as well as a rationale for
this treatment and management plan.
?Reflection notes: What would you do differently in a similar patient evaluation?
pt is a 35 year old black female who weighs 250lbs trying to get pregregnate and she also diganosed with
primary hypertention was placed of procadia 10mg q day .She has never tried to have a baby because she
was so busy building her Law firm .
DO THE SOAP NOTE JUST LIKE THE EXAMPLE PAPER AND MAKE UP STUFF TO FILL IT IN