soap note

 
Students must post one interesting case that he/she has seen in the clinical setting via Discussion Board in the online part of this course. The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan. Notes will be graded as “pass/fail”. In order to receive grade points for SOAP notes, the notes must be approved by the deadlines specified on the course assignments page. The student will lose the opportunity for points on any SOAP notes not approved by the specified deadlines. The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years. 
 
Students must post one interesting case that he/she has seen in the clinical setting via Discussion Board in the online part of this course. The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan. Notes will be graded as “pass/fail”.  In order to receive grade points for SOAP notes, the notes must be approved by the deadlines specified on the course assignments page. The student will lose the opportunity for points on any SOAP notes not approved by the specified deadlines. The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years. 
Clinical Case Grading Criteria: The SOAP note will be submitted through Blackboard. The focus of the presentation must reflect the learning objectives of the course and drawn from the current clinical setting of the student practice site. The evaluation of the presentation is based on the following:    
Chief Complaint & pertinent history
10
 
Pertinent exam and diagnostics
10
 
Working diagnosis with supporting criteria
5
 
Management plan
5
 
Epidemiological data – cited from literature
10
 
Evidenced based rationale for treatment (literature based)
10
 
Analysis of self-care and family issues r/t diagnosis and treatment plan
20
 
Evaluation parameters to be used (or were used) to determine outcomes
10
 
Identify major “lessons learned” and how it may affect your future practice
20
 
Total
100

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