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Learning Goal: I’m working on a nursing project and need an explanation and answer to help me learn.
Create a complete physical examination that will be performed on a person that is 18 years old or older. The physical examination should be no longer than 30 minutes.
As a continuation of this assignment, you will then submit a typed SOAP Note of your physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).
O =Objective data: Including client behavior, physical assessment, vital signs, and meds.
A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.
P =Plan: Treatment, diagnostic testing, and follow up