Sign In
Not register? Register Now!
Essay Available:
Pages:
4 pages/≈1100 words
Sources:
Check Instructions
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Coursework
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 20.74
Topic:

Practicum Experience SOAP Note

Coursework Instructions:

Oral Presentation
Using “OLDCARTS"” present the most interesting patient you have seen in your clinic setting.
The goal of any oral presentation is to pass along the “right amount” of patient information to your preceptor in an efficient fashion. When done well, this enables you and your preceptor to quickly understand the patient’s issues and generate an appropriate plan of action.
As a general rule, oral presentations are shorter than written presentations as they should focus on the most active issues of the day. (Chief Complaint).
Subjective - how patient feels and reports to you. (History)
Objective - vital signs and pertinent physical exam findings; what you hear, feel, smell, and see. (Physical)
Assessment - should include working diagnosis from presenting problem and prior diagnoses that are being actively addressed during the present appointment.
Plan - this is the area that should be very specific as if you are entering the orders.
Some of the most common stumbling blocks for students (other than nerves) include going into too much detail in the subjective and objective sections!
To view the Grading Rubric for this assignment, please visit the Grading Rubrics section of the Course Resources.
Assignment Requirements
Before finalizing your work, you should:
be sure to read the assignment description carefully (as displayed above)
consult the Grading Rubric to make sure you have included everything necessary; and
utilize spelling and grammar check to minimize errors.
Your writing assignment should:
follow the conventions of Standard English (correct grammar, punctuation, etc.);
be well ordered, logical, and unified, as well as original and insightful;
display superior content, organization, style, and mechanics; and
How to Submit
Submit your assignment to the unit Dropbox before midnight on the last day of the unit.
When you are ready to submit your assignment, select the unit Dropbox then attach your file. Please submit both the video and findings into the same Dropbox. Save with your name in the title. Make sure to save a copy of the assignment you submit.

Coursework Sample Content Preview:

Practicum Experience SOAP Note
Student’s Name
University
Course
Professor’s Name
Date
Practicum Experience SOAP Note
Subjective
Chief complaint (CC): MR. E. is a 56-year-old male patient presented the clinic with complaints of a headache and congestion.
HPI: The patient indicated that the onset of the pain was three days ago but had worsened on the fourth day. The patient states that he feels pain and tenderness on his forehead, below the eyes, as well as the sides of the nares. The patient also indicates that he experiences congestion, and some coughing accompanies that. The cough is usually dry, and it gets worse during the night. The patient describes the heading as throbbing, which is worsened by cough. The patient also reports a runny nose with a discharge that is yellow in color. Currently, the patient reports that he has been using Advil and Mucinex to manage the condition, but the effect does not last long. Mr. E also indicates that while he does not experience difficulty performing his daily activities, he has been unable to work for the last two days.
Medications: 200mg Advil, 1200 mg Mucinex per day.
PMH
Allergies: NKDA
Medication Intolerances: N/A
Chronic Illnesses/Major traumas: N/A
Hospitalizations/Surgeries: N/A
Family hx: Patient’s mother is alive but has hypertension. Patient’s father died five years ago due to lung cancer.
Social hx: Patient is divorced, has two daughters, and they keep in contact. He lives alone and is employed at a local general store as the delivery driver and handyman at the store. HE does not smoke but drinks an average of 3 beers per week.
Pertinent ROS
Head: retro-orbital forehead and maxillary sinuses are tenderness to touch
Eyes: pink conjunctiva and white sclera
Ears: pearly grey bilaterally
Nose: nasal mucosa shows a bilateral yellow mucus plugs blocking the turbinate’s, swelling noted to nasal bridge, cheeks pharynx mildly erythema, uvula midline, tonsils 1 + bilaterally, lymph nodes non-palpable neck- supple no palpable masses upon palpation
Respiratory: lung sounds clear bilaterally throughout
HEART: denies and chest pain or SOB
ABD- denies any abdominal symptoms upon examination
Musculoskeletal- denies any back, muscle, or joint pain
Neurological - denies any bowel or bladder incontinence.
Psychiatric – no signs of depression, no self-reported suicidal thoughts.
Objective
Vital Signs
Weight: 175, T: 97.8 °, P: 85, RR: 18, BP: 118/86. Height: 6’3, BMI: 29.9
General Appearance: Healthy in appearance, alert and oriented, answers questions appropriately.
Skin: pale, warm, and clean. Patient does not have rashes or lesions.
HEENT: Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM, no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonery...
Updated on
Get the Whole Paper!
Not exactly what you need?
Do you need a custom essay? Order right now:
Order

You Might Also Like Other Topics Related to the yellow wallpaper:

HIRE A WRITER FROM $11.95 / PAGE
ORDER WITH 15% DISCOUNT!
Order Now