Practicum Experience –Comprehensive SOAP Note and Journal


Practicum Experience –Comprehensive SOAP Note and Journal

After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note: • Subjective: What details did the patient provide regarding his or 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 diagnosis? What was your plan for treatment and management including alternative therapies? • Reflection notes: What would you do differently in a similar patient evaluation?

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