Write a focused SOAP note on a live patient (standardized patient) examined during a “problem visit” from the immersion experience.
Do not disclose the standardized patients legal name, use the patient initials only!
Provide the chief complaint stated during the standardized patient visit. Use quotations for patient’s own words.
Document the HPI using OLDCARTS from the information obtained during your standardized patient visit.
Include all appropriate demographic information for the “ID” Section
Document a focused health history (social history, personal history, family history, review of systems). Only pertinent health history and body systems should be included.
Document a focused physical exam pertinent to the chief complaint. Only pertinent body systems should be included. Include at least two references for your diagnostic and treatment plan. Acceptable references include: peer-reviewed primary sources and clinical practice guidelines (within the last 5 years). The treatment plan must include all components (diagnostic plan, therapeutic plan, education plan, and follow up precautions). If a component is not applicable (i.e diagnostics not indicated), the patient must state that.
This must be an APA-formatted document including a title page, in-text citations, page numbers, and reference page. If any supplementary materials are included (i.e. screening tools, immunization records, etc), they must be incorporated using appropriate APA format.
Submit this SOAP note and immersion documents to the assignment dropbox in D2L
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