Soap Note Gastritis Discussion.

Soap Note Gastritis Discussion.

Soap Note Gastritis Discussion.

 

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1)      Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

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2)      Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3)      Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a)      Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b)      Pertinent positives and negatives must be documented for each relevant system.

c)        Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4)      Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5)      Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6)      Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7)      Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Use APA format and must include minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

  • Soap Note 2 Chronic Conditions
  • You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

    Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

    Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

    The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

    ADDITIONAL INSTRUCTIONS FOR THE CLASS

    Discussion Questions (DQ)

    Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
    Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
    One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
    I encourage you to incorporate the readings from the week (as applicable) into your responses.

    Weekly Participation

    Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
    In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
    Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
    Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

    APA Format and Writing Quality

    Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
    Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
    I highly recommend using the APA Publication Manual, 6th edition.

    Use of Direct Quotes

    I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
    As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
    It is best to paraphrase content and cite your source.

    LopesWrite Policy

    For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
    Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
    Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
    Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

    Late Policy

    The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
    Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
    If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
    I do not accept assignments that are two or more weeks late unless we have worked out an extension.
    As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

    Communication

    Communication is so very important. There are multiple ways to communicate with me:
    Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
    Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Soap Note Gastritis Discussion.

    Soap Note Gastritis Discussion.