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COMMON GYNECOLOGIC HEALTH CONDITIONS FOCUSED SOAP NOTE

VAGINITIS/VAGINAL DISCHARGE

Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses can piece together facts to construct a relevant history that can lead to assessment and treatment. For this Focused Note Assignment, you will select a patient with common gynecologic health conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient. Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin. Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies. Resources Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.

WEEKLY RESOURCES

to prepare · Use the Focused SOAP Note Template found in this week’s Learning Resources to complete this Assignment. · select a patient with common gynecologic health conditions whom you examined during the last three weeks in your practicum experience. With this patient in mind, address the following in your Focused Note Template:

Assignment:

· 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, as well as a rationale for this treatment and management plan. · Reflection notes: What would you do differently in a similar patient evaluation? Note: Your Focused Note Assignment must be signed by Day 7 of Week 7. By Day 7 Submit your Focused Note Assignment. ( Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 7.)

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.