1. Pneumonia Of Left Lung Essay
Pneumonia Of Left Lung EssayPneumonia Of Left Lung Essayse APA format and must
include minimum of 2 Scholarly Citations.Turn it in Score must be less than 15% or will not
be accepted for credit, must be your own work and in your own words.The use of tempates
is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan
should be of your own work and individualized to your made up patientORDER NOW FOR
CUSTOMIZED, PLAGIARISM-FREE PAPERSThis 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.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). Pneumonia Of Left Lung
Essayc) 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/
2. diagnoses identified.7) Clarity of the Write-up(___5pts.): Is it literate, organized and
complete?Comments:Total Score: ____________ Instructor:
__________________________________Guidelines for Focused SOAP Notes· Label each section of the
SOAP note (each body part and system).· Do not use unnecessary words or complete
sentences.· Use Standard AbbreviationsS: SUBJECTIVE DATA (information the
patient/caregiver tells you).Chief Complaint (CC): a statement describing the patient’s
symptoms, problems, condition, diagnosis, physician-recommended return(s) for this
patient visit. The patient’s own words should be in quotes.History of present illness (HPI): a
chronological description of the development of the patient’s chief complaint from the first
symptom or from the previous encounter to the present. Include the eight variables (Onset,
Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment,
Severity-OLDCARTS), or an update on health status since the last patient encounter.Past
Medical History (PMH): Update current medications, allergies, prior illnesses and injuries,
operations and hospitalizations allergies, age-appropriate immunization status.Family
History (FH): Update significant medical information about the patient’s family (parents,
siblings, and children). Include specific diseases related to problems identified in CC, HPI or
ROS.Social History(SH): An age-appropriate review of significant activities that may include
information such as marital status, living arrangements, occupation, history of use of drugs,
alcohol or tobacco, extent of education and sexual history.Review of Systems (ROS). There
are 14 systems for review. List positive findings and pertinent negatives in systems directly
related to the systems identified in the CC and symptoms which have occurred since last
visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth
and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8)
musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric,
(12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should
mirror the PE findings section.0: OBJECTIVE DATA (information you observe, assessment
findings, lab results).Sufficient physical exam should be performed to evaluate areas
suggested by the history and patient’s progress since last visit. Document specific abnormal
and relevant negative findings. Abnormal or unexpected findings should be described. You
should include only the information which was provided in the case study, do not include
additional data.Record observations for the following systems if applicable to this patient
encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs,
general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU,
Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing. The focused PE should only include
systems for which you have been given data.NOTE: Cardiovascular and Respiratory systems
should be assessed on every patient regardless of the chief complaint.Testing Results:
Results of any diagnostic or lab testing ordered during that patient visit.A: ASSESSMENT:
(this is your diagnosis (es) with the appropriate ICD 10 code)List and number the possible
diagnoses (problems) you have identified. These diagnoses are the conclusions you have
drawn from the subjective and objective data.Remember: Your subjective and objective
data should support your diagnoses and your therapeutic plan.Do not write that a diagnosis
is to be “ruled out” rather state the working definitions of each differential or primary
3. diagnosis (es). Pneumonia Of Left Lung EssayFor each diagnoses provide a cited rationale
for choosing this diagnosis. This rationale includes a one sentence cited definition of the
diagnosis (es) the pathophysiology, the common signs and symptoms, the patients
presenting signs and symptoms and the focused PE findings and tests results that support
the dx. Include the interpretation of all lab data given in the case study and explain how
those results support your chosen diagnosis.P: PLAN (this is your treatment plan specific to
this patient). Each step of your plan must include an EBP citation.1. Medications write out
the prescription including dispensing information and provide EBP to support ordering
each medication. Be sure to include both prescription and OTC medications.2. Additional
diagnostic tests include EBP citations to support ordering additional tests3. Education this
is part of the chart and should be brief, this is not a patient education sheet and needs to
have a reference.4. Referrals include citations to support a referral5. Follow up. Patient
follow-up should be specified with time or circumstances of return. You must provide a
reference for your decision on when to follow up
