HSC 1531 Project Clinical Notes

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HSC 1531 Project Clinical Notes

HSC 1531 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:

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Download
the clinical notes for the two patients:

Kay
Salisbury Clinical Notes

Virginia
Thompson Clinical Notes

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:

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