[Recommended] Document Individual Plans Directly
Post a discussion constructed as the ‘P’ (treatment plan) that completes the partial SOAP note accessed through the link above.
Include in the discussion:
- Your treatment “Plan” for the first two diagnoses (see note below on how to structure the ‘P’)
- Citations for each of the evidence-based practice (EBP) interventions included in your Plan
- For each article you cited in support of an element of the Plan, provide your thoughts about the strength of the evidence presented in the article(s)
These are the interventions that relate to each individual, numbered diagnosis.
Document individual plans directly after each corresponding assessment (Ex. Assessment Plan). Address the following aspects (they should be separated out as listed below):
Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your workup for the patient’s chief complaint
Therapeutic: changes in meds, skincare, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications.
Educational: information clients need in order to address their health problems. Include follow up care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.
NOTE: please input N/A where appropriate for the above 4 categories, do not assume that your clinical faculty person will know it was not applicable.
Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.
Please review the rubric to ensure that your response meets the criteria.