Topic: Long Soap note on head foot and mouth disease
write a SOAP note about a patient you have seen in your clinical setting
Expanded Soap Notes Criteria
Understanding the pathological disease processes surrounding the client’s health care concerns allows the student to intelligently and safely vary the plan of care according to each client’s situation as opposed to applying written protocol in the same manner for a widely diverse group of clients.
This section of the SOAP note should briefly discuss the pathophysiological processes pertinent to the client’s specific case. In multiple disease states, an explanation of the effect of one disease process on another must be provided. For instance, if a client has diabetes and hypertension, the student should relate the concomitant pathophysiological processes of the combination of the disease entities.
2. Rationale for Management Plan
This section of the assignment justifies the student’s clinical decision making regarding the selected management plan. It is critical to understand the WHY and HOW of the plan of care and not to become routinely accustomed to any particular regime without first comprehending its purpose. For instance, if an A.C.E. inhibitor was selected over a calcium channel blocker for the initial pharmacological treatment of hypertension, the student should explain the physiology behind their selection of agents and how the pathophysiology of hypertension influences that decision. DO NOT simply cite protocol texts sources but describe the steps behind the management decisions. Documentation for the plan of care must be provided. Use of research articles, current clinical updates and required texts may be used for resources. List in references at end of document.
3. Integration of the Personal Practice Framework
This portion of the assignment should include a brief description of how the student integrated their personal practice framework into the client/family encounter. This must be specific to the patient. For example, if Orem is the primary theorist in the framework, how was self-care addressed during the visit with this patient? If using Leininger, how did the client’s cultural origins/beliefs/values influence the care that was given? You must relate your Personal Practice Framework to this specific patient and patient encounter. Repeating the same information for all expanded notes is not acceptable.
4. Integration of Family Theory
The purpose of this section is to facilitate the student’s use of family theory in each clinical encounter. This section of the assignment should include a brief discussion of the student’s understanding regarding the use of family systems theory, family developmental theory or other appropriate family-oriented framework used in the client/family encounter. Determining the avenue to explore will depend upon each clinical situation and the student should be looking for subtle clues the client may exhibit. For example: Was the family constellation assessed? 2) Was the client’s role within the family system assessed in relationship to the presenting complaint? 3) Did the family’s developmental stage influence the care given? 4) Was the referral source chosen based on the impending family crisis? 5) How was the client’s health affected by the ability to care for the other family members? 6) How does the chronic illness of the client affect the family system? 7) Will the change in the client’s behavior occur based upon previous role rigidity in the other family members? You must relate your integration of family theory to this specific patient and patient encounter. Repeating the same information for all expanded notes is not acceptable.
Selecting a concept to analyze or a specific family theory to use may be helpful in the initial attempts to writing this section.
5. Cost analysis
This section assists the student in understanding the cost of health care and its impact on the patient as well as the health care system. As the student gains employment, it is essential to understand the obvious and the hidden rationing of health care that occurs secondary to cost containment and policy decisions from various payers. The student must calculate the actual cost of the visit to the client and to the system. The cost of the visit, diagnostic tests ordered, pharmaceuticals prescribed, treatments rendered, etc should be calculated. Furthermore, consideration must be given to payment sources i.e, cash, insurance, pre-authorized services.
6. Ethical considerations
Bioclinical ethics have not kept pace with medical technology. Consequently, health care providers frequently encounter ethical quandaries in clinical practice. Bioclinical ethics teaches practitioners that the human dimensions of ethics and values are not less – and perhaps even more important to our well-being than more tangible realities (Sharkey & White, 1995). Application and understanding of ethical principles is a professional necessity. For a review, please read Chapter 8 in your 635 Text: Jansen & Zwygart-Stauffer (2006). Advanced practice nursing. Springer: New York, New York.
The student should select an ethical theory and specific principle and analyze the clinical case based upon its parameters. Value conflicts may be identified and options for resolution may be discussed. This should apply specifically to this patient.
You must relate the ethical concerns related to this specific patient and patient encounter. Repeating the same information for all expanded notes is not acceptable.
7. Cultural considerations
You must relate the cultural considerations related to this specific patient and patient encounter. Repeating the same information for all expanded notes is not acceptable.
8. Self critique
What would you do differently in this case? What did you do well? What will you do next time you have a patient like this, i.e, what have you learned in the analysis of this patient’s case? What have you learned about doing the initial SOAP note?