Assignment : Practicum - SOAP Note and Time Log
Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
• Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
• 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? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes: What was your "aha" moment? What would you do differently in a similar patient evaluation?
You will submit this Week 7 SOAP Note along with your Journal Entries (from Weeks 5, 6, and 7) and Practicum Time Log.
Practicum - Journal Entry
Reflect on a patient who presented with cardiovascular or genetic disorders during your Practicum experience.
Describe your experience in assessing and managing the patient and his or her family. Include details of your "aha" moment in identifying the patient's disorder.
Then, explain how the experience connected your classroom studies to the real-world clinical setting.
If you did not have an opportunity to evaluate a patient with this background during the last 8 weeks, you may select a related case study from a reputable source or reflect on previous clinical experiences.