Purpose
The purpose of this assignment is to give you practice writing professional SOAP notes.
Overview
Remember that SOAP notes promote organization of thinking and use of the Nursing Process. continue to use the template provided and follow the rubric for guidance.
Information submitted must not include any confidential identifying patient information.
Focused SOAP Notes
Usually, we describe a focused (or episodic) visit as when a patient comes in who is ill with a complaint such as URI or UTI. The patient may be someone who also comes in for chronic condition visits, but this particular visit is focused on the chief complaint. It is helpful to differentiate between the types of visits the same person might make. For example, when your diabetic patient comes in because of a UTI, you are only focusing on the “sick or illness” complaint.
Comprehensive SOAP Notes
A comprehensive SOAP note is describes an office visit that is more thorough not focused on just one complaint. This may be an annual physical exam or follow up on chronic condition(s). It involves assessment of more body systems. For example, for a routine follow up on diabetes, you will want the patient to schedule a different appointment.
The rubrics will also help you see how the two types of SOAP notes differ.
Please note: When documenting assessment or review of systems, use proper descriptive terms. Do not write “normal” or “negative” in the assessment.
When you get into practice, it will be important to understand that billing for services will depend on having proper documentation in all areas of the patient’s chart. When a patient is charged for services and the chart does not support the billing code, it can be considered fraudulent and serious consequences could result.
To avoid violating HIPAA guidelines, do not use the patient’s name, address or SSN. Please be sure to put your own name on the assignment being submitted.
Action Items
- Using the guidelines in the overview and the provided templateDownload provided template, write a comprehensive SOAP note. Only one well visit permitted for comprehensive SOAP note assignments (per semester).
- Review your note for accuracy, privacy protection, and thoroughness.