During this assignment it was the first time I was introduced to a soap note. I had no prior knowledge of how the information was broken down and reported into the different sections. What made it even harder to write the soap note was the patient had already been treated and had fully recovered. As I reflect back on my soap note I noticed some mistakes that I made. One mistake I made was I included the differential in the objective section. When I wrote “chest film revealed a diffuse infiltrate indication of ARDS” I feel it should have instead read “chest film revealed a diffuse infiltrate”.One other part of the soap note I found to be challenging was the plan section it was confusing as to which information I should include about the patient, since the plan had already been initiated. Here I chose a time during the patient’s visit before the plan was made and worked from there. Finally, I feel since the patient had come in for hypotension as the initial symptom I should have wrote my summary on hypotension and not ARDS. ARDS is only one of the diseases that can be connected to hypotension and it is important to touch on some of the others diseases that should be taken into consideration when it comes to hypotension. The summary was limited in providing a better understanding of hypotension and could have been better. From this experience I learned that writing a soap note will require more practice on my part, and I am hoping that my writing skills will improve with more practice.
