Managing The Patient in The Clinic Setting Essay Assignment

Week 3 Discussion

• SOAP format is the documentation style you will be using in your clinicals, this also adheres to the thought processes involved in formulating the correct diagnosis and treatment plan. You will present the subjective data first, including all questions that you want to ask. Next is gathering of objective data that supports your subjective data; if there is none given, then you will determine by system what kind of physical exam elements you want to elicit. After this, you are ready to provide differentials and a working diagnosis based on the above data. After arriving at the appropriate working diagnosis, you will then formulate a treatment plan. Please be sure to follow the template below for your initial discussion board postings. Postings should be concise and NOT in narrative format. 
• Case for the SOAP note is the Following:
  

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Prompt: Calvin is a 36-year-old lawyer who is coming in today for a worsening cough over the past four days. He has had some yellow sputum sporadically throughout the day; he says he has felt hot but has not taken his temperature. He has a history of asthma and has been using his Proventil inhaler every 2 to 3 hours for the past 3 to 4 days. He has no other medication. He says that other than the cough, he feels a little fatigued, and he notices that his energy level is less when he plays hockey with his men’s league twice a week.  His SaO2 is 96%, HR 102, and BP 144/82. He has bilateral wheezes posteriorly on inspiration, worse at the base. Managing The Patient in The Clinic Setting Essay Assignment

Soap Template 

Case Study Chosen: (List what case you have chosen, above case) 

Demographics: Age/Gender 

SUBJECTIVE

• • CC: 
  • HPI: (As listed from Case Study Information)
  • Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent).  

OBJECTIVE

General:

• • VSBP, HR, RR, Weight, Height, BMI
  • Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)  
  • POC Testing (any Point of Care (POC) testing specifically performed in the office): What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none. Managing The Patient in The Clinic Setting Essay Assignment

ASSESSMENT

• • Working Diagnosis:  (Must include ICD 10)
  • Differential Diagnosis: 

PLAN

• • Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will be ordering for your patient. Remember the importance of appropriate resource utilization. Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL.
• • Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only list drug class. Should follow evidence-based guidelines.
  • Referrals: If Applicable 
  • Education:
  • Health maintenance:
  • RTC: Managing The Patient in The Clinic Setting Essay Assignment