Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :
Subjective: What details did the patient provide regarding 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? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters for this patient , as well as a rationale for this treatment and management plan.
Very Important: Reflection notes: What would you do differently in a similar patient evaluation?
Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Womenâ€™s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
Chapter 6, â€œCare of the Well Woman Across the Life Spanâ€ ,â€œCare of the Woman Interested in Barrier Methods of Birth Controlâ€ (pp. 275â€“278)
Chapter 7, â€œCare of the Woman with Reproductive Health Problemsâ€
â€œCare of the Woman with Dysmenorrheaâ€ (pp. 366â€“368)
â€œCare of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)â€ (pp. 414â€“418)