Overview
Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses can piece together facts to construct a relevant history that can lead to assessment and treatment.
For this Focused Note Assignment, you will select a patient with gynecologic conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.
To prepare:
- Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.
- Select a patient that you examined during the last three weeks. With this patient in mind, address the following in your Focused Note Template.
Assignment
- 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 diagnosis? 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?
* PATIENT- 53 year old female, presented to clinic due to having post menopausal bleeding. Performed pelvic exam, and ultrasound of the uterus. (You can base the soap note off of this patient, add any information you would like, this is just what it should be based off of.) (Does not need to be too detailed, as long as it matches the template requirements.)