Unit 7 Journal

SOAP Note

This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on the virtual reality patient you evaluated in Unit 6.

The core aspects of the SOAP note are described in detail below.

For ease of learning, a SOAP note template has been provided. This assignment requires proper citation and referencing because this is an academic paper.

S: Subjective information. Everything the patient tells you. This includes several areas including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLD CARTS, which includes: onset, location, duration, characteristics, aggravating factors, relieving factors, treatments, and severity.

O: Objective is what you see, hear, feel or smell. Your physical exam includes vital signs.

A: Assessment/your differentials.

P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.

If there are any questions, please contact your instructor.

PLEASE FOLLOW THE SOAP NOTE AS STATED , IT HAS TO BE EXACTLY IN THIS SOAP NOTE TEMPLATE FORMAT , MAKE SURE TO FILL ALL THE REQUIRED ENTRIES ON THE SOAP NOTE , THAT NOTHING OF WHAT IT IS ASKED FOR IN THE TEMPLATE IS MISSING

.Unit 6

?Case: Samuel Olsen

?Scenario QUESTION: Samuel is a two-year-old with his mother Anna at the primary care clinic with a two-day history of decreased appetite, fever, pulling at both ears and “fussiness.” 

[PCS spark Patient]