SOAP Note

Select a geriatric patient that you examined during the last 3 weeks. The patient you select should be currently taking at least five prescription and/or over-the-counter drugs. With this patient in mind, address the following in a SOAP Note:

Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding his or her personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the Beers Criteria and consider alternative drugs if appropriate.

Objective: What observations did you make during the physical assessment? What functional assessments were used?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from top priority to least priority.

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? What is your care plan for patient? How would you offer caregiver support?

Reflection notes: What would you do differently in a similar patient evaluation? How might you improve your assessment, diagnosis, and/or plan through interprofessional collaboration?