ASSIGNMENT : SOAP Note

Assignment 2 – SOAP Note – Complex Women’s Health

Directions

Select a patient and perform a comprehensive woman’s exam.
The patient should have at least one acute and one chronic issue.
Complete a complex SOAP note using the template provided.
Include all relevant subjective data for the patient’s complaints.
Present all relevant objective clinical findings.
Include differential and medical diagnoses with references and rationales.
Create a plan of care including all diagnostic studies, meds, education, health promotion/screening by age, ethical and cultural considerations, follow up, and referrals.
Be sure to include no personal identifying patient data.
Please follow the grading rubric for specific grading criteria.

SAMPLE SOLUTION

SOAP Note
Subjective
A 28-year-old African American single female comes in for contraceptive information regarding having a copper containing ParaGuard inserted. The patient is diabetic and currently on Metformin ER 2000mg PO daily. She does not report any other problem. Her last normal menstrual period ended 3 days ago.
Objective
On examination, the patient is in fair general condition. She is afebrile, has no pallor, no jaundice, no cyanosis, no lympadenopa…