This document is a Unit Two Journal entry, specifically a SOAP note (Subjective, Objective, Assessment, Plan) completed by a student, Vivian Lopez, in the NP I - Primary Care of Women's Health (MN576) course at Purdue University Global. It represents a practice application of clinical documentation skills.
This assignment is intended for students learning to document patient encounters. It’s used to demonstrate understanding of the SOAP note format and the initial steps in a well-woman exam. It exists as a graded component of the course, assessing a student’s ability to synthesize patient information.
This SOAP note does *not* represent a complete patient chart or a finalized clinical assessment. It is a learning exercise. It also does not include a comprehensive plan of care, beyond the initial assessment noted.
This document provides a sample patient encounter, including subjective information gathered from a patient presenting to establish primary care, objective findings from a physical exam, and a preliminary assessment. It includes sections for Chief Complaint, History of Present Illness, Medications, Allergies, Past Medical History, Family History, Social History, and a focused physical exam. The document also lists initial lab tests ordered and a primary diagnosis. This preview does *not* include the full assessment and plan sections, nor does it contain instructor feedback.