Soap Note for patient with a GI disorder (Irritable Bowel Disease
After completing this week’s Practicum Experience, select a patient whom you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
•Subjective: What details did the patient provide regarding his or 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?
•Reflection notes: What would you do differently in a similar patient evaluation?
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