As a nurse practitioner , select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note ( 2 PAGES)
•Subjective: What details did the patient provide regarding his or her personal and medical history?
•Objective: What observations did you make during the physical assessment?
•Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
•Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?
•Reflection notes: What would you do differently in a similar patient evaluation?
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.
◦Part 11, “Evaluation and Management of Cardiovascular Disorders” (pp. 487–611)
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.
◦Chapter 26, “Recording Information
National Heart Lung and Blood Institute. (2002). Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. Retrieved from http://www.nhlbi.nih.gov/files/docs/resources/heart/pphbp.pdf
American Heart Association. (n.d.). Retrieved November 28, 2012, from http://www.heart.org/HEARTORG
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