NU650 (January 2021) Week 5 Assignment Soap Note
NU 650 Advanced Health Assessment
Week 5 Assignment
Overview
The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit relate
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NU650 (January 2021) Week 5 Assignment Soap Note
NU 650 Advanced Health Assessment
Week 5 Assignment
Overview
The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in the previous week’s learning materials. Review the SOAP Note Rubric. Use a case from the previous week’s discussion or patient from your video submission or clinical practicum experience (adding content as needed to represent abnormal findings). Submit your own note. Do not submit documentation from the patient’s record.
How I Completed this Assignment
Since I am not in the clinical setting I spoke with my sister about her vestibular migraines. I wrote up the SOAP not as if she was coming in for a physical and also need blood work done due the use of Topamax. Then the diagnosis and plan were written up as if assessment were taking place prior to diagnosis and treatment of vestibular migraines.
SUBJECTIVE DATA IDENTIFYING DATA
Initials: A.
Age: 30
Race: Caucasian Gender: Female Marital Status: Single
Source: Patient – appears to be a reliable source of information, alert and orients to person, place, time, and situation; ready recall and understanding of medical HX
CHIEF COMPLAINT : “I am here for my yearly physical. I also need to have blood work done because I take Topamax for vestibular migraines”
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