For this weeks discussion, we will be looking at local or nationaShainaBoling829
For this week's discussion, we will be looking at local or national response protocols that were initiated during a critical incident, and you will choose your topic!
Search reputable local and national media for a man-made disaster to discuss.
Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks.
In your initial post, describe the incident and address the following:
· Determine the incident type and explain your reasoning.
· What resources were deployed for this incident?
· What protocols were implemented successfully, and which were unsuccessful?
· Discuss way to improve the response to this type of incident in the future.
Support your answer with evidence. Please provide a working link to your story source.
NUR 634 SOAP Note Guide and Template
Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type ...
Comprehensive SOAP TemplateThis template is for a full history.docxmaxinesmith73660
Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Patient Initials: _______
Age: _______
Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Mu.
For this assignment, you are to complete aclinical case - narr.docxsleeperharwell
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment wit.
SOAP NOTE TEMPLATEPlease role play with a volunteer family mem.docxwhitneyleman54422
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source). Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice The term “Rule Out…” cannot be used as a diagnosis. Please describe appearance of area assessed and refrain from using the term “normal” when documenting this note. Please note that requirements for SOAP notes may differ across NP courses.
I. Subjective Data
A. Chief Complain (CC):
B. History of Present Illness (HPI):
C. Last Menstrual Period (LMP- if applicable)
D. Allergies:
E. Past Medical History:
F. Family History:
G. Surgery History:
H. Social History (alcohol, drug or tobacco use):
I. Health Maintenance: ( include last PAP/MAM, immunizations, colonoscopy, PSA, last eye & physical exam, etc.)
J. Lifestyle Patterns (include spiritual beliefs, behaviors, and traditional practices)
K. Current medications:
L. Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
II. Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess additional pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
A. Assessment
Differential Diagnosis (include rationales and cite source)
1.
2.
3.
Medical Diagnosis (include ICD 10 codes)
1.
B: PLAN
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Cultural & Life span considerations
6. Referrals
Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
Please include CPT Code (level of visit)
References: Please include at least 3 evidence-based sources in APA format.
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will
focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will
include evidence
-
based practice guidelines in the management plan,
and include rationales for
differential diagnoses (cite .
APA Title page, running head, page numbers, reference sheet. Use L.docxjustine1simpson78276
APA Title page, running head, page numbers, reference sheet. Use Level 1 and 2 headings to make identifying the components of the paper easier. – 5 points after grade calculated from rubric.
TO be successful in the clinical setting do the following:
You need a APA cover sheet, running head and reference page for anything you turn in (Journal, SOAP note, Time Log).
Do Not change the template.
Do use the template located in the Doc Sharing. This is the explanation of the template…this is not the template.
READ every line of this document please.
You must site 2 journal articles in addition to Epocrates/Medscape and text book failure to do so is -10 points outside of the rubric.
All grades are final. No revisions. Do not ask for revisions of SOAP grades.
Nurse Practitioner SOAP Notes
Purpose: To explain what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise. DO NOT INCLUDE IN NOTE
Subjective data value @ 15 points
SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion
Chief Complaint (CC): One to three words explaining why patient came to clinic value 1 point
History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom: value 7 points hint: OLD CART
Write your paragraph in the order of old cart & chart as well if missing paragraph -3.5 if missing list -3.5
Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments/Therapies
Each of these are valued at 0.5 points (maximum 4 points)
Medications: list each one by name with dosage and frequency
Allergies: include specific reactions to medications, foods, insects, environmental
Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses
Past Surgical History (PSH): Dates, indications and types of operations
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function
Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history etc
Immunizations: Last Tdp, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age)
Family History: Parents, Grandparents, siblings, children
Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you. Delete the system if not addressing. DO NOT put wnl or no complaints be specific. Value 3 points
General: any recent weight changes, weakness, fatigue,.
For this assignment, you are to complete aclinical case - narrat.docxsleeperharwell
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment with a.
Comprehensive SOAP Template
Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Includelast Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic:
Endocrine:
Allergic/Immunolog.
For this weeks discussion, we will be looking at local or nationaShainaBoling829
For this week's discussion, we will be looking at local or national response protocols that were initiated during a critical incident, and you will choose your topic!
Search reputable local and national media for a man-made disaster to discuss.
Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks.
In your initial post, describe the incident and address the following:
· Determine the incident type and explain your reasoning.
· What resources were deployed for this incident?
· What protocols were implemented successfully, and which were unsuccessful?
· Discuss way to improve the response to this type of incident in the future.
Support your answer with evidence. Please provide a working link to your story source.
NUR 634 SOAP Note Guide and Template
Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type ...
Comprehensive SOAP TemplateThis template is for a full history.docxmaxinesmith73660
Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Patient Initials: _______
Age: _______
Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Mu.
For this assignment, you are to complete aclinical case - narr.docxsleeperharwell
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment wit.
SOAP NOTE TEMPLATEPlease role play with a volunteer family mem.docxwhitneyleman54422
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source). Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice The term “Rule Out…” cannot be used as a diagnosis. Please describe appearance of area assessed and refrain from using the term “normal” when documenting this note. Please note that requirements for SOAP notes may differ across NP courses.
I. Subjective Data
A. Chief Complain (CC):
B. History of Present Illness (HPI):
C. Last Menstrual Period (LMP- if applicable)
D. Allergies:
E. Past Medical History:
F. Family History:
G. Surgery History:
H. Social History (alcohol, drug or tobacco use):
I. Health Maintenance: ( include last PAP/MAM, immunizations, colonoscopy, PSA, last eye & physical exam, etc.)
J. Lifestyle Patterns (include spiritual beliefs, behaviors, and traditional practices)
K. Current medications:
L. Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
II. Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess additional pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
A. Assessment
Differential Diagnosis (include rationales and cite source)
1.
2.
3.
Medical Diagnosis (include ICD 10 codes)
1.
B: PLAN
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Cultural & Life span considerations
6. Referrals
Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
Please include CPT Code (level of visit)
References: Please include at least 3 evidence-based sources in APA format.
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will
focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will
include evidence
-
based practice guidelines in the management plan,
and include rationales for
differential diagnoses (cite .
APA Title page, running head, page numbers, reference sheet. Use L.docxjustine1simpson78276
APA Title page, running head, page numbers, reference sheet. Use Level 1 and 2 headings to make identifying the components of the paper easier. – 5 points after grade calculated from rubric.
TO be successful in the clinical setting do the following:
You need a APA cover sheet, running head and reference page for anything you turn in (Journal, SOAP note, Time Log).
Do Not change the template.
Do use the template located in the Doc Sharing. This is the explanation of the template…this is not the template.
READ every line of this document please.
You must site 2 journal articles in addition to Epocrates/Medscape and text book failure to do so is -10 points outside of the rubric.
All grades are final. No revisions. Do not ask for revisions of SOAP grades.
Nurse Practitioner SOAP Notes
Purpose: To explain what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise. DO NOT INCLUDE IN NOTE
Subjective data value @ 15 points
SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion
Chief Complaint (CC): One to three words explaining why patient came to clinic value 1 point
History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom: value 7 points hint: OLD CART
Write your paragraph in the order of old cart & chart as well if missing paragraph -3.5 if missing list -3.5
Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments/Therapies
Each of these are valued at 0.5 points (maximum 4 points)
Medications: list each one by name with dosage and frequency
Allergies: include specific reactions to medications, foods, insects, environmental
Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses
Past Surgical History (PSH): Dates, indications and types of operations
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function
Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history etc
Immunizations: Last Tdp, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age)
Family History: Parents, Grandparents, siblings, children
Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you. Delete the system if not addressing. DO NOT put wnl or no complaints be specific. Value 3 points
General: any recent weight changes, weakness, fatigue,.
For this assignment, you are to complete aclinical case - narrat.docxsleeperharwell
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment with a.
Comprehensive SOAP Template
Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Includelast Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic:
Endocrine:
Allergic/Immunolog.
see attachments I have complete a portion of the assignment but needPazSilviapm
see attachments I have complete a portion of the assignment but need the rest of the
Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from your current clinical experience.
2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page
(Page 1)
:
Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective
(Start of Page 2)
:
Follow APA guidelines for running head on page 2 and subsequent pages.
CC:
chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI:
history of present illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH:
past medical history - This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies:
State the offending medication/food and the reactions.
Medications:
Names, dosages, and routes of administration.
Social history:
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Click on the link below to explore the CDC’s information on the ‘social determinants of health’.
https://www.cdc.gov/socialdeterminants/
Family history:
Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion:
Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
Click on the link below to access information about c ...
Diagnostic and Clinical Reasoning Paper AssignmentThe purposmackulaytoni
Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from your current clinical experience.
2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page
(Page 1)
:
Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective
(Start of Page 2)
:
Follow APA guidelines for running head on page 2 and subsequent pages.
CC:
chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI:
history of present illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH:
past medical history - This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies:
State the offending medication/food and the reactions.
Medications:
Names, dosages, and routes of administration.
Social history:
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Click on the link below to explore the CDC’s information on the ‘social determinants of health’.
https://www.cdc.gov/socialdeterminants/
Family history:
Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion:
Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
Click on the link below to access information about current guidelines.
https://www.uspreventiveservicestaskforce.org/
Review of Systems (R ...
Choose one skin condition graphic Shingles # 5 (identify by num.docxtroutmanboris
Choose one skin condition graphic Shingles # 5 (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to the Comprehensive SOAP Template (see below template). Remember that not all comprehensive SOAP data are included in every patient case.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of
three to five
possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from Learning Resources.
#5 Shingles
Comprehensive SOAP Template
Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA:
Include what the patient tells you, but organize the information.
Chief Complaint (CC):
In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI):
This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of
each principal symptom
:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications:
Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies:
Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH):
Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH):
Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable,
include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History:
Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History:
Include last Tdp, Flu, pneumonia, etc.
Significant Family History:
Include history of parents, Grandparents, siblings, and children.
Lifestyle:
Include cultural factors, .
[Type here]Rasmussen University Be sure all outside soTatianaMajor22
[Type here]
Rasmussen University
Be sure all outside sources are cited using current APA style.
Write from nursing perspective
In text citation
Three references
Used the medical diagnosis (gestational diabetes) by giving their pathophysiology, causes, risk factors, signs and symptom/clinical, complication, and treatment and fill all the concept map below
CONCEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Preterm Labor
Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)
Complications
Treatment (Medical, medications, intervention and supportive)
Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)
.
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.
PLAN OF CARE:Use your top two priorities
NANDA NURSING DIAGNOSIS use NANDA definition
Expected outcomes of care (Goals)
Interventions
Patient response
Goal evaluation
NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
Short term goal: Create a SMART goal that relates to hospital stay/shift/day.
Long term goal: Create a SMART goal that is appropriate for discharge.
This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
Interventions for short-term goal:
1.
2.
3.
Interventions for long term goal:
1.
2.
3.
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)
Reassess for short-term goal:
1.
2.
3.
Reassess for long-term goal:
1.
2.
3.
Was it met or not met there is no partially met.
Summer 2021 JM 9
[Type here]
Be sure all outside sources are cited using current APA style.
Write from
nursing
perspective
In text citation
Three references
Used the medical diagnosis
(gestational
diabetes)
by giving their pathophysiology, causes, risk factors, signs and
symptom/clinical, complication, and treatment
and
fill all the concept map
below
CON
CEPT MAP
Pathophysiology
–
(to the cellular level)
Medical Diagnosis
Preterm Labor
Signs &
Symptoms/
Clinical
Manifestations
(all data subjective
and objective: labs, radiology, all
diagnostic
studies) (
What symptoms
does your client present with?)
Complications
Treatment
(Medical, medications,
intervention and supportive)
Causes/
Risk Facto
rs
(chemical,
environmental, psychological, physiological
and genetic
)
[Type here]
Be sure all outside sources are cited using current APA style.
Write from nursi ...
School of Nursing and Allied HealthMSN Case Write Up Assignmen.docxWilheminaRossi174
School of Nursing and Allied Health
MSN Case Write Up Assignment
The purpose of the Case Write-Up Assignment is for your instructor to "see" what you are doing in clinical and "see" how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.
Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.
Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, add an addendum at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.
If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write an addendum at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum.
You are learning to practice evidence-based practice. Support the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your write up is using a research article.
Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)
Note that you
CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups
All case write ups are to be submitted to the appropriate assignment category by the due date. Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requ.
SOAP NOTE TEMPLATEPlease include a heart exam and lung exam o.docxaryan532920
SOAP NOTE TEMPLATE
Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis.
Subjective Data
Chief Complain (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP- if applicable)
Allergies:
Past Medical History:
Family History:
Surgery History:
Social History (alcohol, drug or tobacco use):
Current medications:
Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
Assessment
A: Differential Diagnosis Please rule out all differential diagnosis with subjective and objective data and/or lab-work.
1.
2.
3.
B: Medical Diagnosis Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis.
1.
PLAN
A: Orders
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Referrals
B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
KAPLAN SCHOOL OF NURSING
SOAP NOTE/CASE STUDY GRADING RUBRIC
[100 Points Total]
A. Project Content
80 points possible
0
1-5
6-10
11-15
16-20
Score
Presentation of Case, subjective and
No paper submitted
Needs improvement
Partially addressed case and/or Subjective Data. Only 4-6 components addressed.
Partially addressed Case and/or Subjective Data.
Only 7-9 components addressed.
Clearly and thoroughly presents Case and Subjective Data.
All 10 components addressed
20
Objective Data
No Paper submitted
Omitted 5 or more components of the objective data
Omitted 3-4 components of the objective data
Omitted 1-2 components of the objective data
Clearly and thoroughly presents Objective Data. All of the relevant systems addressed based on the CC and HPI
20
Assessment
No Paper submitted
Failed to address the diagnosis and/or differential diagnosis
Diagnosis incorrect but completed a thorough exam and lab work in order to rule in diagnosis
Diagnosis correct but failed to rule in diagnosis with exams or ...
Your final project for this course will be a patient record analysis.docxlanagore871
Your final project for this course will be a patient record analysis. You will apply the knowledge of anatomy, physiology, and pharmacology that you have developed during this course in a thorough review of existing patient information. Specifically, you will review a patient’s history and a discharge chart from a recent physician visit, explaining the reasons behind diagnosis
or (diagnoses) based on documented symptoms. You will also cite any inconsistencies or concerns and discuss potential and current treatments, all in preparation for your future coding practices. It may seem unnecessary to learn so much about pathophysiology and pharmacology for a career in health information management, but such knowledge is essential in ensuring the accuracy of patient records, coding, and billing.
The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Three and Five. The final product will be submitted in Module Seven.
In this assignment, you will demonstrate your mastery of the following course outcomes:
·
Analyze the pathophysiology of commonly diagnosed health conditions for anticipating the pharmacological needs of patients
·
Differentiate between common health conditions that present similar symptoms using evidence - based resources for ensuring accurate patient health records
·
Analyze standard pharmacological groupings and their specific drugs for their uses in treating patient symptoms and diseases
·
Integrate foundational concepts of anatomy, physiology, and medical terminology into the analysis of symptoms, diagnosis, and treatment options for informing accurate coding practices
Prompt
Your patient analysis should answer the following prompt
Using the provided Final Project Patient File (attached), critically analyze the patient’s medical and family history and dissect the discharge chart from the patient’s recent visit. There are several inaccuracies and inconsistencies in this patient file; the pages of the file that contain issues are marked in the upper right - hand corner with red bookmarks. You must identify a total of three true issues with the patient file, explain what makes each identified issue a true issue, and discuss how you would approach addressing each issue in a real professional setting. Specifically, the following critical elements must be addressed:
I.
Patient History Analysis
a) Summarize the
patient history
, explaining key patient demographics and family history that could be risk factors for common diseases.
b) Identify the
past diagnosis
(or diagnoses, if more than one exists in the file) and explain how the diagnosis was made. Specifically, what tests were done?
c) Discuss the
symptoms
the patient showed according to the file. Why and how did these symptoms lead the doctors to order certain tests?
d) What
alternate diagnosis
(or diagnose.
Your final project for this course will be a patient record analysis.docxamirawaite
Your final project for this course will be a patient record analysis. You will apply the knowledge of anatomy, physiology, and pharmacology that you have developed during this course in a thorough review of existing patient information. Specifically, you will review a patient’s history and a discharge chart from a recent physician visit, explaining the reasons behind diagnosis
or (diagnoses) based on documented symptoms. You will also cite any inconsistencies or concerns and discuss potential and current treatments, all in preparation for your future coding practices. It may seem unnecessary to learn so much about pathophysiology and pharmacology for a career in health information management, but such knowledge is essential in ensuring the accuracy of patient records, coding, and billing.
The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Three and Five. The final product will be submitted in Module Seven.
In this assignment, you will demonstrate your mastery of the following course outcomes:
·
Analyze the pathophysiology of commonly diagnosed health conditions for anticipating the pharmacological needs of patients
·
Differentiate between common health conditions that present similar symptoms using evidence - based resources for ensuring accurate patient health records
·
Analyze standard pharmacological groupings and their specific drugs for their uses in treating patient symptoms and diseases
·
Integrate foundational concepts of anatomy, physiology, and medical terminology into the analysis of symptoms, diagnosis, and treatment options for informing accurate coding practices
Prompt
Your patient analysis should answer the following prompt
Using the provided Final Project Patient File (attached), critically analyze the patient’s medical and family history and dissect the discharge chart from the patient’s recent visit. There are several inaccuracies and inconsistencies in this patient file; the pages of the file that contain issues are marked in the upper right - hand corner with red bookmarks. You must identify a total of three true issues with the patient file, explain what makes each identified issue a true issue, and discuss how you would approach addressing each issue in a real professional setting. Specifically, the following critical elements must be addressed:
I.
Patient History Analysis
a) Summarize the
patient history
, explaining key patient demographics and family history that could be risk factors for common diseases.
b) Identify the
past diagnosis
(or diagnoses, if more than one exists in the file) and explain how the diagnosis was made. Specifically, what tests were done?
c) Discuss the
symptoms
the patient showed according to the file. Why and how did these symptoms lead the doctors to order certain tests?
d) What
alternate diagnosis
(or diagnose.
Soap Note 2 Chronic Conditions (asthma)Pick any Chronic Dise.docxpbilly1
Soap Note 2 Chronic Conditions (asthma)
Pick any Chronic Disease from Weeks 6-10 (asthma)
Must use the sample template for your soap note
, keep this template for when you start clinicals.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include a minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
The use of the templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.
(Student Name)
Miami Regional
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Patricio Bidart MSN, APRN, FNP-C
Soap Note #
____ Main Diagnosis ______________
PATIENT INFORMATION
Name
:
Age
:
Gender at Birth:
Gender Identity
:
Source
:
Allergies
:
Current Medications:
•
PMH:
Immunizations:
Preventive Care
:
Surgical History
:
Family History
:
Social History
:
Sexual Orientation
:
Nutrition History
:
Subjective Data:
Chief
Complaint
:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS)
(This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL
:
NEUROLOGIC
:
HEENT
:
RESPIRATORY
:
CARDIOVASCULAR
:
GASTROINTESTINAL
:
GENITOURINARY
:
MUSCULOSKELETAL
:
SKIN
:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE
:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example :
“Pt came in to our clinic c/o of ear
pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that
etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis
(minimum 3)
-
-
-
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
• - • -
Pharmacological treatment:
-
Non-Pharmacologic treatment
:
Education
(provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References
(in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
.
Mrs. G, a 55 year old Hispanic female, presents to the office for he.docxaudeleypearl
Mrs. G, a 55 year old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep.
Current medications:
Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin
PMH:
Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to
date.
GYN hx:
G2 P1. 1 SAB, 1 living child, full term, wt 9lbs 2 oz. LMP 15months ago. No history of abnormal Pap smear.
FH:
parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol.
SH:
works from home part time as a planning coordinator. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use
Allergies
: NKDA, allergic to cats and pollen. No latex allergy
Vital signs
: BP 129/80; pulse 76, regular; respiration 16, regular
Height 5’2.5”, weight 185 pounds
General:
obese female in no acute distress. Alert, oriented and cooperative.
Skin
: warm dry and intact. No lesions noted
HEENT:
head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV
: S1 and S2 RRR without murmurs or rubs
Lungs
: Clear to auscultation bilaterally, respirations unlabored.
Abdomen
- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.
Labwork:
CBC
:
WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC
34 g/dl RDW 13.8%
UA:
pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones
CMP:
Sodium 139
Potassium 4.3
Chloride 100
CO2 29
Glucose 95
BUN 12
Creatinine 0.7
GFR est non-AA 92 mL/min/1.73 GFR est AA 101 mL/min/1.73 Calcium 9.5
Total protein 7.6 Bilirubin, total 0.6 Alkaline.
5 Tips for Writing an Effective Case Report - In medicine, a case report is a detailed report of the signs, symptoms, diagnosis, treatment, and follow-up of an individual patient. It describes an unexpected presentation of an illness.
Writing a case report is an integral part of scientific writing
Case study of the biotechnology industry in medicine – pubricaPubrica
Five potential contributions to the defence of case report publication include:
• A new disease has been identified and described.
• Rare manifestations of a known disease are recognized.
• The discovery of a disease's mechanisms
• Detection of harmful or favourable drug side effects (and other treatments)
• Medical auditing and education
•
Learn More : https://bit.ly/3Kkgyx5
Reference: https://pubrica.com/services/research-services/case-report-writing/
Why Pubrica:
When you order our services, we promise you the following – Plagiarism free | always on Time | 24*7 customer support | Written to international Standard | Unlimited Revisions support | Medical writing Expert | Publication Support | Bio statistical experts | High-quality Subject Matter Experts.
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Blog: https://pubrica.com/academy/
Email: sales@pubrica.com
WhatsApp : +91 9884350006
United Kingdom: +44-1618186353
Case study of the biotechnology industry in medicine – pubricaPubrica
Five potential contributions to the defence of case report publication include:
• A new disease has been identified and described.
• Rare manifestations of a known disease are recognized.
• The discovery of a disease's mechanisms
• Detection of harmful or favourable drug side effects (and other treatments)
• Medical auditing and education
•
Learn More : https://bit.ly/3Kkgyx5
Reference: https://pubrica.com/services/research-services/case-report-writing/
Why Pubrica:
When you order our services, we promise you the following – Plagiarism free | always on Time | 24*7 customer support | Written to international Standard | Unlimited Revisions support | Medical writing Expert | Publication Support | Bio statistical experts | High-quality Subject Matter Experts.
Contact us:
Web: https://pubrica.com/
Blog: https://pubrica.com/academy/
Email: sales@pubrica.com
WhatsApp : +91 9884350006
United Kingdom: +44-1618186353
see attachments I have complete a portion of the assignment but needPazSilviapm
see attachments I have complete a portion of the assignment but need the rest of the
Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from your current clinical experience.
2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page
(Page 1)
:
Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective
(Start of Page 2)
:
Follow APA guidelines for running head on page 2 and subsequent pages.
CC:
chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI:
history of present illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH:
past medical history - This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies:
State the offending medication/food and the reactions.
Medications:
Names, dosages, and routes of administration.
Social history:
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Click on the link below to explore the CDC’s information on the ‘social determinants of health’.
https://www.cdc.gov/socialdeterminants/
Family history:
Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion:
Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
Click on the link below to access information about c ...
Diagnostic and Clinical Reasoning Paper AssignmentThe purposmackulaytoni
Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from your current clinical experience.
2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page
(Page 1)
:
Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective
(Start of Page 2)
:
Follow APA guidelines for running head on page 2 and subsequent pages.
CC:
chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI:
history of present illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH:
past medical history - This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies:
State the offending medication/food and the reactions.
Medications:
Names, dosages, and routes of administration.
Social history:
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Click on the link below to explore the CDC’s information on the ‘social determinants of health’.
https://www.cdc.gov/socialdeterminants/
Family history:
Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion:
Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
Click on the link below to access information about current guidelines.
https://www.uspreventiveservicestaskforce.org/
Review of Systems (R ...
Choose one skin condition graphic Shingles # 5 (identify by num.docxtroutmanboris
Choose one skin condition graphic Shingles # 5 (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to the Comprehensive SOAP Template (see below template). Remember that not all comprehensive SOAP data are included in every patient case.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of
three to five
possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from Learning Resources.
#5 Shingles
Comprehensive SOAP Template
Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA:
Include what the patient tells you, but organize the information.
Chief Complaint (CC):
In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI):
This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of
each principal symptom
:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications:
Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies:
Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH):
Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH):
Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable,
include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History:
Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History:
Include last Tdp, Flu, pneumonia, etc.
Significant Family History:
Include history of parents, Grandparents, siblings, and children.
Lifestyle:
Include cultural factors, .
[Type here]Rasmussen University Be sure all outside soTatianaMajor22
[Type here]
Rasmussen University
Be sure all outside sources are cited using current APA style.
Write from nursing perspective
In text citation
Three references
Used the medical diagnosis (gestational diabetes) by giving their pathophysiology, causes, risk factors, signs and symptom/clinical, complication, and treatment and fill all the concept map below
CONCEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Preterm Labor
Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)
Complications
Treatment (Medical, medications, intervention and supportive)
Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)
.
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.
PLAN OF CARE:Use your top two priorities
NANDA NURSING DIAGNOSIS use NANDA definition
Expected outcomes of care (Goals)
Interventions
Patient response
Goal evaluation
NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
Short term goal: Create a SMART goal that relates to hospital stay/shift/day.
Long term goal: Create a SMART goal that is appropriate for discharge.
This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
Interventions for short-term goal:
1.
2.
3.
Interventions for long term goal:
1.
2.
3.
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)
Reassess for short-term goal:
1.
2.
3.
Reassess for long-term goal:
1.
2.
3.
Was it met or not met there is no partially met.
Summer 2021 JM 9
[Type here]
Be sure all outside sources are cited using current APA style.
Write from
nursing
perspective
In text citation
Three references
Used the medical diagnosis
(gestational
diabetes)
by giving their pathophysiology, causes, risk factors, signs and
symptom/clinical, complication, and treatment
and
fill all the concept map
below
CON
CEPT MAP
Pathophysiology
–
(to the cellular level)
Medical Diagnosis
Preterm Labor
Signs &
Symptoms/
Clinical
Manifestations
(all data subjective
and objective: labs, radiology, all
diagnostic
studies) (
What symptoms
does your client present with?)
Complications
Treatment
(Medical, medications,
intervention and supportive)
Causes/
Risk Facto
rs
(chemical,
environmental, psychological, physiological
and genetic
)
[Type here]
Be sure all outside sources are cited using current APA style.
Write from nursi ...
School of Nursing and Allied HealthMSN Case Write Up Assignmen.docxWilheminaRossi174
School of Nursing and Allied Health
MSN Case Write Up Assignment
The purpose of the Case Write-Up Assignment is for your instructor to "see" what you are doing in clinical and "see" how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.
Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.
Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, add an addendum at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.
If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write an addendum at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum.
You are learning to practice evidence-based practice. Support the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your write up is using a research article.
Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)
Note that you
CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups
All case write ups are to be submitted to the appropriate assignment category by the due date. Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requ.
SOAP NOTE TEMPLATEPlease include a heart exam and lung exam o.docxaryan532920
SOAP NOTE TEMPLATE
Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis.
Subjective Data
Chief Complain (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP- if applicable)
Allergies:
Past Medical History:
Family History:
Surgery History:
Social History (alcohol, drug or tobacco use):
Current medications:
Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
Assessment
A: Differential Diagnosis Please rule out all differential diagnosis with subjective and objective data and/or lab-work.
1.
2.
3.
B: Medical Diagnosis Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis.
1.
PLAN
A: Orders
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Referrals
B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
KAPLAN SCHOOL OF NURSING
SOAP NOTE/CASE STUDY GRADING RUBRIC
[100 Points Total]
A. Project Content
80 points possible
0
1-5
6-10
11-15
16-20
Score
Presentation of Case, subjective and
No paper submitted
Needs improvement
Partially addressed case and/or Subjective Data. Only 4-6 components addressed.
Partially addressed Case and/or Subjective Data.
Only 7-9 components addressed.
Clearly and thoroughly presents Case and Subjective Data.
All 10 components addressed
20
Objective Data
No Paper submitted
Omitted 5 or more components of the objective data
Omitted 3-4 components of the objective data
Omitted 1-2 components of the objective data
Clearly and thoroughly presents Objective Data. All of the relevant systems addressed based on the CC and HPI
20
Assessment
No Paper submitted
Failed to address the diagnosis and/or differential diagnosis
Diagnosis incorrect but completed a thorough exam and lab work in order to rule in diagnosis
Diagnosis correct but failed to rule in diagnosis with exams or ...
Your final project for this course will be a patient record analysis.docxlanagore871
Your final project for this course will be a patient record analysis. You will apply the knowledge of anatomy, physiology, and pharmacology that you have developed during this course in a thorough review of existing patient information. Specifically, you will review a patient’s history and a discharge chart from a recent physician visit, explaining the reasons behind diagnosis
or (diagnoses) based on documented symptoms. You will also cite any inconsistencies or concerns and discuss potential and current treatments, all in preparation for your future coding practices. It may seem unnecessary to learn so much about pathophysiology and pharmacology for a career in health information management, but such knowledge is essential in ensuring the accuracy of patient records, coding, and billing.
The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Three and Five. The final product will be submitted in Module Seven.
In this assignment, you will demonstrate your mastery of the following course outcomes:
·
Analyze the pathophysiology of commonly diagnosed health conditions for anticipating the pharmacological needs of patients
·
Differentiate between common health conditions that present similar symptoms using evidence - based resources for ensuring accurate patient health records
·
Analyze standard pharmacological groupings and their specific drugs for their uses in treating patient symptoms and diseases
·
Integrate foundational concepts of anatomy, physiology, and medical terminology into the analysis of symptoms, diagnosis, and treatment options for informing accurate coding practices
Prompt
Your patient analysis should answer the following prompt
Using the provided Final Project Patient File (attached), critically analyze the patient’s medical and family history and dissect the discharge chart from the patient’s recent visit. There are several inaccuracies and inconsistencies in this patient file; the pages of the file that contain issues are marked in the upper right - hand corner with red bookmarks. You must identify a total of three true issues with the patient file, explain what makes each identified issue a true issue, and discuss how you would approach addressing each issue in a real professional setting. Specifically, the following critical elements must be addressed:
I.
Patient History Analysis
a) Summarize the
patient history
, explaining key patient demographics and family history that could be risk factors for common diseases.
b) Identify the
past diagnosis
(or diagnoses, if more than one exists in the file) and explain how the diagnosis was made. Specifically, what tests were done?
c) Discuss the
symptoms
the patient showed according to the file. Why and how did these symptoms lead the doctors to order certain tests?
d) What
alternate diagnosis
(or diagnose.
Your final project for this course will be a patient record analysis.docxamirawaite
Your final project for this course will be a patient record analysis. You will apply the knowledge of anatomy, physiology, and pharmacology that you have developed during this course in a thorough review of existing patient information. Specifically, you will review a patient’s history and a discharge chart from a recent physician visit, explaining the reasons behind diagnosis
or (diagnoses) based on documented symptoms. You will also cite any inconsistencies or concerns and discuss potential and current treatments, all in preparation for your future coding practices. It may seem unnecessary to learn so much about pathophysiology and pharmacology for a career in health information management, but such knowledge is essential in ensuring the accuracy of patient records, coding, and billing.
The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Three and Five. The final product will be submitted in Module Seven.
In this assignment, you will demonstrate your mastery of the following course outcomes:
·
Analyze the pathophysiology of commonly diagnosed health conditions for anticipating the pharmacological needs of patients
·
Differentiate between common health conditions that present similar symptoms using evidence - based resources for ensuring accurate patient health records
·
Analyze standard pharmacological groupings and their specific drugs for their uses in treating patient symptoms and diseases
·
Integrate foundational concepts of anatomy, physiology, and medical terminology into the analysis of symptoms, diagnosis, and treatment options for informing accurate coding practices
Prompt
Your patient analysis should answer the following prompt
Using the provided Final Project Patient File (attached), critically analyze the patient’s medical and family history and dissect the discharge chart from the patient’s recent visit. There are several inaccuracies and inconsistencies in this patient file; the pages of the file that contain issues are marked in the upper right - hand corner with red bookmarks. You must identify a total of three true issues with the patient file, explain what makes each identified issue a true issue, and discuss how you would approach addressing each issue in a real professional setting. Specifically, the following critical elements must be addressed:
I.
Patient History Analysis
a) Summarize the
patient history
, explaining key patient demographics and family history that could be risk factors for common diseases.
b) Identify the
past diagnosis
(or diagnoses, if more than one exists in the file) and explain how the diagnosis was made. Specifically, what tests were done?
c) Discuss the
symptoms
the patient showed according to the file. Why and how did these symptoms lead the doctors to order certain tests?
d) What
alternate diagnosis
(or diagnose.
Soap Note 2 Chronic Conditions (asthma)Pick any Chronic Dise.docxpbilly1
Soap Note 2 Chronic Conditions (asthma)
Pick any Chronic Disease from Weeks 6-10 (asthma)
Must use the sample template for your soap note
, keep this template for when you start clinicals.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include a minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
The use of the templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.
(Student Name)
Miami Regional
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Patricio Bidart MSN, APRN, FNP-C
Soap Note #
____ Main Diagnosis ______________
PATIENT INFORMATION
Name
:
Age
:
Gender at Birth:
Gender Identity
:
Source
:
Allergies
:
Current Medications:
•
PMH:
Immunizations:
Preventive Care
:
Surgical History
:
Family History
:
Social History
:
Sexual Orientation
:
Nutrition History
:
Subjective Data:
Chief
Complaint
:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS)
(This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL
:
NEUROLOGIC
:
HEENT
:
RESPIRATORY
:
CARDIOVASCULAR
:
GASTROINTESTINAL
:
GENITOURINARY
:
MUSCULOSKELETAL
:
SKIN
:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE
:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example :
“Pt came in to our clinic c/o of ear
pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that
etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis
(minimum 3)
-
-
-
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
• - • -
Pharmacological treatment:
-
Non-Pharmacologic treatment
:
Education
(provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References
(in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
.
Mrs. G, a 55 year old Hispanic female, presents to the office for he.docxaudeleypearl
Mrs. G, a 55 year old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep.
Current medications:
Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin
PMH:
Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to
date.
GYN hx:
G2 P1. 1 SAB, 1 living child, full term, wt 9lbs 2 oz. LMP 15months ago. No history of abnormal Pap smear.
FH:
parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol.
SH:
works from home part time as a planning coordinator. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use
Allergies
: NKDA, allergic to cats and pollen. No latex allergy
Vital signs
: BP 129/80; pulse 76, regular; respiration 16, regular
Height 5’2.5”, weight 185 pounds
General:
obese female in no acute distress. Alert, oriented and cooperative.
Skin
: warm dry and intact. No lesions noted
HEENT:
head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV
: S1 and S2 RRR without murmurs or rubs
Lungs
: Clear to auscultation bilaterally, respirations unlabored.
Abdomen
- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.
Labwork:
CBC
:
WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC
34 g/dl RDW 13.8%
UA:
pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones
CMP:
Sodium 139
Potassium 4.3
Chloride 100
CO2 29
Glucose 95
BUN 12
Creatinine 0.7
GFR est non-AA 92 mL/min/1.73 GFR est AA 101 mL/min/1.73 Calcium 9.5
Total protein 7.6 Bilirubin, total 0.6 Alkaline.
5 Tips for Writing an Effective Case Report - In medicine, a case report is a detailed report of the signs, symptoms, diagnosis, treatment, and follow-up of an individual patient. It describes an unexpected presentation of an illness.
Writing a case report is an integral part of scientific writing
Case study of the biotechnology industry in medicine – pubricaPubrica
Five potential contributions to the defence of case report publication include:
• A new disease has been identified and described.
• Rare manifestations of a known disease are recognized.
• The discovery of a disease's mechanisms
• Detection of harmful or favourable drug side effects (and other treatments)
• Medical auditing and education
•
Learn More : https://bit.ly/3Kkgyx5
Reference: https://pubrica.com/services/research-services/case-report-writing/
Why Pubrica:
When you order our services, we promise you the following – Plagiarism free | always on Time | 24*7 customer support | Written to international Standard | Unlimited Revisions support | Medical writing Expert | Publication Support | Bio statistical experts | High-quality Subject Matter Experts.
Contact us:
Web: https://pubrica.com/
Blog: https://pubrica.com/academy/
Email: sales@pubrica.com
WhatsApp : +91 9884350006
United Kingdom: +44-1618186353
Case study of the biotechnology industry in medicine – pubricaPubrica
Five potential contributions to the defence of case report publication include:
• A new disease has been identified and described.
• Rare manifestations of a known disease are recognized.
• The discovery of a disease's mechanisms
• Detection of harmful or favourable drug side effects (and other treatments)
• Medical auditing and education
•
Learn More : https://bit.ly/3Kkgyx5
Reference: https://pubrica.com/services/research-services/case-report-writing/
Why Pubrica:
When you order our services, we promise you the following – Plagiarism free | always on Time | 24*7 customer support | Written to international Standard | Unlimited Revisions support | Medical writing Expert | Publication Support | Bio statistical experts | High-quality Subject Matter Experts.
Contact us:
Web: https://pubrica.com/
Blog: https://pubrica.com/academy/
Email: sales@pubrica.com
WhatsApp : +91 9884350006
United Kingdom: +44-1618186353
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...
Pneumonia Of Left Lung Essay.docx
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