HSC1531 Module 02 Course Project – Clinical Notes

 

In this course project assignment, you are presented with clinical notes for two different patients. These progress notes have been recorded as SOAP notes. A SOAP note is a common method of documenting a patient’s visit with a healthcare provider. These notes are saved in a patient’s medical record and will be used for treatment, billing, and other activities to monitor the patient’s health over time.

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. Each of these components is used to record a vital part of the patient’s visit.

• Subjective: Includes the patient’s complaints and states the patient’s symptoms in his or her own words

• Objective: Includes information that the provider can measure, such as vital signs, weight, or findings from a physical exam

• Assessment: Includes a differential diagnosis or summary of signs and symptoms

• Plan: Includes treatments performed, follow-up appointment information, referrals, or other orders

You will be exploring the medical terminology used in these SOAP notes and will be asked to interpret the meanings of various words and abbreviations.

To complete this assignment, do the following:

1. Download the clinical notes for the two patients:

   Kay Salisbury Clinical Notes

   Virginia Thompson Clinical Notes

2. Download, complete, and submit the document below. This document contains questions you will answer regarding the clinical notes for each patient.

   Module 02 Course Project Assignment Template

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below:

Jstudent_exampleproblem_101504

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