Comprehensive Patient Assessment (Soap Note)

Comprehensive Patient Assessment (Soap Note) Application – Comprehensive Patient Assessment When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting. By Day 7 of Week 9 This Assignment is due. It is highly recommended that you begin planning and working on this Assignment as soon as it is viable. To prepare • Reflect on your Practicum Experience and select a female patient whom you have examined with the support and guidance of your Preceptor. o The Chief Complaint of the female patient is Abdominal and back pain for 5 days. She states that she has experience a thick white, foul-smelling discharge for 2 days with a with a thick vaginal discharge with a streak of blood • Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care. To complete Write an 8- to 10-page comprehensive paper that addresses the following: • Age, race and ethnicity, and partner status of the patient • Current health status, including chief concern or complaint of the patient • Contraception method (if any) • Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem) • Review of systems • Physical exam • Labs, tests, and other diagnostics • Differential diagnoses o Chlamydia trachomatis o Neisseria gonorrhea o Trichomonas vaginalis o Bacterial vaginosis Please explain the differential diagnosis in great detail • Management plan, including diagnosis, treatment, patient education, and follow-up care Note: Refer to the Comprehensive Write-up Guide in this week’s Learning Resources for a detailed outline with additional guidance.