Quality and Safety Education for Nurses



Family Nurse PractitionerRequired SOAP Notes for Each Clinical SemesterExpectations: Each semester, you will be tasked with completing Subjective, Objective, Assessment and Plan (SOAP) notes on a variety of patients you have directly cared for at your clinical site. The goal of this exercise is to build your knowledge, skill in, and attitude of providing evidence-based care in a safe and effective manner within your scope of family practice. Each semester will build upon previous semester knowledge. These SOAP notes will allow you to demonstrate your ability to integrate subjective and objective information gathering into formulation of diagnoses and development of a patient-centered, evidence-based plan of care for patients of all ages. Directions: Locate your current semester below to identify the required SOAP notes to be submitted. Due dates will be located within your current course calendar. Please see the specific rubric for each semester to identify complete assignment requirements. Templates are located within each course/semester to guide your writing. Semester One:Of the 5 SOAP notes submissions, 4 of them are REQUIRED to be one of each of the following (in no particular order):Wellness visit, adult, 13-64 years of ageWellness visit, geriatric, 65 years of age or olderEncounter for immunizationScreening for Lipoid disorderFor 1 of the 5 SOAP note submissions, you may CHOOSE from the following list:Well-child visit, 2-12 years of ageScreening for Diabetes MellitusScreening for Colorectal cancerSchool/Sports physical Semester Two:Of the 5 Pediatric SOAP note submissions, 4 of them are REQUIRED to be one of each of the following (in no particular order): Abdominal PainAsthmaOtitisWell-child, age newborn to 12 (there will be no differentials for this patient)For 1 of the 5 Pediatric SOAP note submissions, you may CHOOSE from the following list: ADD/ADHDDermatology complaintCoughFeverPharyngitisOf the 5 Women’s Health SOAP note submissions, 4 of them are REQUIRED to be one of each of the following (in no particular order): Bacterial Vaginosis/Vaginal CandidiasisUTISTI or STI exposureWell female exam (there will be no differentials for this patient)For 1 of the 5 Women’s Health SOAP note submissions, you may CHOOSE from the following list: Abnormal pap smearBreast complaintMenorrhagiaOral Contraceptive/Hormone Replacement Therapy (HRT)PCOSSemester Three:Of the 10 SOAP note submissions, 7 of them are REQUIRED to be one of each of the following (in no particular order): COPD/AsthmaDiabetes Mellitus Type 2General Anxiety Disorder and/or Major Depressive DisorderHyperlipidemiaHypertensionSinusitis (Viral or ABRS)Thyroid DisordersFor 3 of the 10 SOAP note submissions, you may CHOOSE from the following list: Autoimmune DisordersDementiaDermatologyHA/MigraineInfectious DiseaseMS complaintPharyngitisPneumoniaSemester Four: Of the 10 SOAP note submissions, 4 of them are REQUIRED to be one of each of the following (in no particular order):HTN follow-upDMT2 follow-upPatient needing referral for collaborative carePatient with multiple co-morbid conditions (3 at minimum, which could be DMT2, HTN, and Dyslipidemia) needing medication adjustmentFor 5 SOAP notes submissions, you may CHOOSE from the following list (any topic from the list provided in NUR61300 and/or NUR62300):UTI, STI, STI exposure, BV, Candidiasis, PCOS, abnormal pap smear, breast complaint, oral contraceptive/HRT counseling, menorrhagia ADD/ADHD, fever, pharyngitis, allergic contact dermatitis, irritant dermatitis, abdominal painHTN, Dyslipidemia, DMT2, COPD/Asthma, GAD/MDD, Viral URI, ABRS, CAP, dementia, HA/Migraine, MS complaint, thyroid disorderFor 1 SOAP note submission, you may CHOOSE any topic not on the list and of interest to you (if you so choose) ................
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