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Case Study:
Instructions
Identify a friend, peer, or family member you can inter
Case Study:
Instructions
Identify a friend, peer, or family member you can interview.
Collect information to construct a complete and comprehensive subjective data set consistent with documentation requirements for a new patient scheduled for an annual wellness exam.
Conduct an interview.
Document your findings on the provided SOAP note template. Structure the subjective data set on the SOAP note template in the format provided in your lecture materials.
Submit the Word file containing your subjective data set on the SOAP note template to this assignment dropbox by Sunday at 11:59 pm CT.Resources
Resources:
Bickley, L.S. (2023). Overview: Physical examination and history taking. Bates’ guide to physical examination and history-taking, 13thed. Revised. New York: Lippincott, Williams, & Wilkins. ISN-13:9781975210533
Chapter 4 – Health History
Chapter 8 – General Survey, Vital Signs and Pain
Chapter 9 – Cognition, Behavior, and Mental Status
SOAP NOTES:
The SOAP note is used by providers to document is an organized manner which reflects clinical reasoning. The SOAP note is an acronym which stands for Subjective, Objective, Assessment and Plan. The focus of this lecture will be on subjective and objective parts. Click on each heading below to read more.
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