Assignment: Practicum Experience – SOAP Note and Journal

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?
Please refer to the Learning Resources in Week 3 for guidance on writing SOAP Notes.

Rubric Detail

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Name: NURS_6531_Week_7_Application_Rubric

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Quality of Work Submitted:

The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.–
Excellent 27 (27%) – 30 (30%)
Good 24 (24%) – 26 (26%)
Fair 21 (21%) – 23 (23%)
Poor 0 (0%) – 20 (20%)
Quality of Work Submitted:
The purpose of the paper is clear.–
Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3.5 (3.5%) – 3.5 (3.5%)
Poor 0 (0%) – 3 (3%)
Assimilation and Synthesis of Ideas:
The extend to which the work reflects the student’s ability to:

Understand and interpret the assignment’s key concepts.–
Excellent 9 (9%) – 10 (10%)
Good 8 (8%) – 8 (8%)
Fair 7 (7%) – 7 (7%)
Poor 0 (0%) – 6 (6%)
Assimilation and Synthesis of Ideas:
The extend to which the work reflects the student’s ability to:

Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.–
Excellent 18 (18%) – 20 (20%)
Good 16 (16%) – 17 (17%)
Fair 14 (14%) – 15 (15%)
Poor 0 (0%) – 13 (13%)
Assimilation and Synthesis of Ideas:
The extend to which the work reflects the student’s ability to:

Synthesize (combines various components or different ideas into a new whole) material in course resources (i.e. video, required readings, textbook) and outside, credible resources by comparing different points of view and highlighting similarities, differences, and connections.–
Excellent 18 (18%) – 20 (20%)
Good 16 (16%) – 17 (17%)
Fair 14 (14%) – 15 (15%)
Poor 0 (0%) – 13 (13%)

Written Expression and Formatting

Paragraph and Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance.–
Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3.5 (3.5%) – 3.5 (3.5%)
Poor 0 (0%) – 3 (3%)
Written Expression and Formatting

English writing standards: Correct grammar, mechanics, and proper punctuation–
Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3.5 (3.5%) – 3.5 (3.5%)
Poor 0 (0%) – 3 (3%)
Written Expression and Formatting

The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.–
Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3.5 (3.5%) – 3.5 (3.5%)
Poor 0 (0%) – 3 (3%)
Total Points: 100

Practicum Experience – SOAP Note and Journal

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