Assignment: Each student will individually submit a SOAP format note, to be based on a real clinical encounter

Assignment: Each student will individually submit a SOAP format note, to be based on a real clinical encounter

Assignment: Each student will individually submit a SOAP format note, to be based on a real clinical encounter

Each student will individually submit a SOAP format note, to be based on a real clinical encounter. This will be a FOCUSED return antepartum visit with a risk factor or PROBLEM as the Chief Complaint in addition to the ROUTINE care for that particular gestational age. The woman may have a discomfort which might actually be normal in pregnancy but there is always a differential for each discomfort to be considered. She might have a chronic condition, prior diagnosis or at-risk status you are monitoring. (Examples: Pre-eclampsia, headaches, gestational diabetes or preexisting diabetes, size/date discrepancy, domestic violence or suspicion thereof, abnormal labs, PTL or risk thereof, nausea, abdominal or back pain, urinary frequency, excessive weight gain/loss etc.)

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Pass/ Fail Criteria:
The assignment will be evaluated as PASS/ FAIL and will be repeated as needed until mastery is demonstrated. Your submission will be posted in the designated Discussion area in Canvas, and students can comment on submissions. To facilitate reading and comments, post directly into the text box, NOT as an attachment. Students are expected to read all submissions, comments and feedback for maximum learning. Faculty feedback should be incorporated into subsequent postings so PLEASE read prior comments/ feedback prior to posting. See template provided in “Clinical” Module section for guidance in format. Since the rest of the chart will not be available, precede the SOAP with a brief introduction of age, gravida/para, ethnicity only if relevant to risk, gestational age and how established, onset of care and number of visits to date, and any SIGNIFICANT findings from prior history.
Category Criteria
Thorough Includes an introduction then all significant positives and negatives in history and exam, point-of-care lab results, reasonable list of DDx (limited to 4 maximum), complete plans including diagnostics (lab/imaging), education, anticipatory guidance, nonpharmacologic and pharmacologic interventions, alternative, complementary or self-care treatment as indicated, counseling etc. plus plans for next visit and any other follow-up.
Accurate Use of terminology and descriptors, precise and relevant
Format Appropriate use of categories (SOAP)
Resources Up-to-date and relevant resources (minimum 5, course textbooks acceptable)

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