GCU Diagnosis and Treatment of Multiligament Knee Injury SOAP Note Form Template
Description
The goal of this assignment is to introduce to the SOAP note format. A SOAP template has been provided below for your use. You will read the Mixed-up Soap Note Scenario. You will identify the Subjective components in the narrative. You will take that data that youve been given, and you will enter the data in the appropriate area on the Soap note, you will want to abbreviate the content and complete a Review of Systems. There is limited objective data. You will then contemplate the information that youve been given, and from this information, you will create a diagnosis and a plan. You will complete the SOAP note, and you can utilize the second document to present your rationales and research.What you will see is that you can do the majority of your Diagnosis with an excellent history.Focus your diagnoses on what you see.Often as a provider, you start your diagnoses based on a physical finding or a complaint and then you will fine tune it based on your examination or other tests. For example, a patient presents with a cough based on history; you may then determine the patient is having respiratory distress through observation, you will then continue to fine tune your diagnosis to Wheezing with your examination and then once you have finished you have narrowed it down to Mild intermittent Asthma with exacerbation.This process will start with a vague diagnosis and become more specific as you gather more specific data.
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