Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.
Select a patient with gastrointestinal or genitourinary condition that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 codes for the diagnosis. 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? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?