Nursing – Obstetrics Comprehensive Patient Assessment – Soap Note
When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment that focuses on one female patient from your current practicum setting.
Reflect on your Practicum Experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care. Nursing – Obstetrics Comprehensive Patient Assessment – Soap Note.
Write an 8- to 10-page comprehensive assessment that addresses the following:
Age, race and ethnicity, and partner status of the patient
Current health status, including chief concern or complaint of the patient
Contraception method (if any)
Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem). Nursing – Obstetrics Comprehensive Patient Assessment – Soap Note.
Review of systems
Labs, tests, and other diagnostics
Management plan, including diagnosis, treatment, patient education, and follow-up care