SOAP Note Clinical Practice
Please ensure that the Discussion includes more than 400 words with scholarly articles, and the plagiarism level must remain below 20%.
Soap Note 1 is based on the Case Study # 1
You MUST use the Case Study #1 as the base of this SOAP NOTE #1
Must use the sample template for your soap note, keep this template for when you start clinicals.
Templates used from another classes will not be accepted. Student must use the template provided in this class which must clearly contain the progress note (in the Assessment section) of the encounter with the patient ( this section is clearly mark in bold, highlighted and underlined). No passing grade will be granted if this section is not completed properly.
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Late Assignment Policy
Assignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get grade of 0 (zero). No exceptions
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 25% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated.
Please see College Handbook with reference to Academic Misconduct Statement.
The use of tempates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.
Importance of SOAP Note Clinical Practice
SOAP notes are vital in documenting patient care and guiding clinical decision-making. They help maintain clear communication among healthcare providers. The structure supports a systematic review of patient issues, improving safety and accuracy (Podder et al., 2020). The subjective section records patient-reported symptoms and concerns. Objective data include measurable findings such as vital signs or lab results. Together, they build a full picture of the patient’s condition.
Transitioning to the assessment, nurses synthesize data to arrive at a clinical impression. This portion is critical to identifying the correct diagnosis. For example, recognizing subtle changes in symptoms can suggest complications. The plan section outlines specific interventions. These may include medications, lifestyle advice, or follow-up appointments. This logical progression allows for continuity and efficiency in patient care…………….
Evidence-Based Approach in SOAP Notes
The SOAP note enhances clinical accuracy when paired with scholarly evidence. For instance, including current guidelines in the plan supports optimal care (Bickley & Szilagyi, 2020). Documentation should reflect individualized decisions based on the patient’s unique presentation. Cultural, social, and emotional aspects must also be considered. This demonstrates holistic, patient-centered care.
Transitions between SOAP sections must flow logically. When well-written, the note provides a clear roadmap for ongoing care. It also aids in auditing and performance review. Finally, SOAP notes reduce errors by ensuring consistent and complete documentation………..
