Academic clinical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems in formulating an evidence-based plan of care.
You are required to have two (minimum) of each of the following:
- Progress SOAP Notes
Develop a progress SOAP note or a full history and physical examination note based on your clinical patient experience. What observations did you note? What questions were raised that required further exploration? Characterize your patient interaction activities.
Refer to the “Clinical SOAP Note Rubric” resource in the Topic Materials for the expectations and requirements for each type of note.