Instructions from my professor:
Soap Note 1. Heart Failure.
Must use the sample template for your soap note.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include minimum of 2 Scholarly Citations.
TURN-It-In (anti-Plagiarism program) will be used.
The use of tempates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.
You must use template for Soap note 1. Use the information provided in the PDF as an “EXAMPLE”. You must use the word temple file and tailor it to your patient and their diagnosis. Using this template will make it very easy to learn the things needed in the note and help you not forget to put something or lose points due to incorrect format or missing information.
The Chief Complaint, Patient info, HPI, Plan section, and references must all be of your own work and no copy-paste.
The Main Areas of Focus that will be checked for plagiarism is Chief Complain, History of Present Illness (HPI), Assessment with Rationale and Explanation, and the Plan. All of this should be in your own words and not copy-pasted from a past note or website or book. There should be minimum likeness noted by turn it in software in these areas.
The Objective and Subjective information can be from a template (Standard Documentation) and will only be looked at for content and not for plagiarism. So if you are past 50% and the above main areas of focus sections are clear and minimum then you are ok. You can resubmit as many times but after 3 it takes up to 24 hours to get turn it in a score.
This is a made-up patient, so review your diagnosis and have the patient have the standard presentation, objective and subjective symptoms that would typically present and adjust them on.
Note: Soap Note Template, (mandatory use) is attached.
Soap Note sample (PDF) is attached.
Soap Note rubric (for grading) is also attached.
APA 7th edition
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