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Soap Note

Soap Note

Discussion: Unit 7, Due Wednesday by 11:59 pm CT

Clinical Experience


It is anticipated that the initial discussion post should be in the range of 250-300 words.

Response posts to peers have no minimum word requirement but must demonstrate topic

knowledge and scholarly engagement with peers. Substantive content is imperative for all

posts. All discussion prompt elements for the topic must be addressed. Please proofread your

response carefully for grammar and spelling. Do not upload any attachments unless specified

in the instructions. All posts should be supported by a minimum of one scholarly resource,

ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and

references must adhere to APA format.

Classroom Participation:

Students are expected to address the initial discussion question by Wednesday of each week.

Participation in the discussion forum requires a minimum of three (3) substantive postings (this

includes your initial post and posting to two peers) on three (3) different days. Substantive

means that you add something new to the discussion supported with citation(s) and

reference(s), you are not just agreeing. This is also a time to ask questions or offer information

surrounding the topic addressed by your peers. Personal experience is appropriate for a

substantive discussion, however, should be correlated to the literature.

All discussion boards will be evaluated utilizing rubric criteria inclusive of content, analysis,

collaboration, writing, and APA. If you fail to post an initial discussion or initial discussion is

late, you will not receive points for content and analysis, you may however post to your peers

for partial credit following the guidelines above.

Initial Discussion Question/Prompt [Due Wednesday]

Consider the following questions in your initial discussion post:


Review the SOAP note accessed through the link below.

Unit 7 SOAP Note


Utilize the information below that is copied-and-pasted out of the SOAP Note

Assignment instructions to assist you in formatting your post:

Assessment (A):

Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each


A statement of current condition and all other chronic illnesses that were addressed during the

visit must be included (i.e. HTN-well managed on medication}.

Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this

diagnosis (or these diagnoses if more than one is listed}. Pertinent positives and negatives

must be found in the write-up.

Plan (P):

These are the interventions that relate to each individual, numbered diagnosis.

Document individual plans directly after each corresponding assessment (Ex.

Assessment Plan). Address the following aspects (they should be separated out as listed


Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter

that you plan to review/evaluate relative to your work up for the patient’s chief complaint

Therapeutic: changes in meds, skin care, counseling, include full prescribing information for

any pharmacologic interventions including quantity and number of refills for any new or refilled


Educational: information clients need in order to address their health problems. Include follow-

up care. Anticipatory guidance and counseling.

Consultation/Collaboration: referrals or consult while in clinic with another provider. If no

referral made was there a possible referral you could make and why? Advance care planning.

NOTE: please input N/A where appropriate for the above 4 categories, do not assume that

your clinical faculty person will know it was not applicable.

Responses need to address all components of the question, demonstrate critical thinking and

analysis and include peer-reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with in-text citations and corresponding

references in APA format.

Please review the rubric to ensure that your response meets the criteria.

Estimated time to complete: 2 hours

Discussion Peer/Participation Prompt [Due Sunday]

Search entries or author

 Reply

Please respond to at least 2 of your peer’s posts with substantive comments using the

following steps:

Construct a response – ideally one who utilized the same EBP interventions that you did

and one who did not.

Substantive comments add to the discussion and provide your fellow students with

information that will enhance the learning environment.

References and citations should conform to APA standards.

Remember: Please respect the opinions of others, even if their views differ. In other

words, disagree professionally and respectfully.

Plagiarism is never acceptable – give credit when credit is due – cite your sources.

Responses need to address all components of the question, demonstrate critical thinking and

analysis and include peer-reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with in-text citations and corresponding

references in APA format.

Please review the rubric to ensure that your response meets the criteria. Collaboration points

will be forfeited if you fail to meet the response post guidelines.

Estimated time to complete: 1 hour

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