BB week 6 soap

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Home>Homework Answsers>Nursing homework helpBb week 6 soap20 days ago11.06.202515Report issuefiles (2)SOAPNoteTemplate-Final281293.docxSOAPNoteTemplate-Final281293.docxSOAPNoteTemplate-Final281293.docxSOAP Note _______NU___:_________Herzing UniversityName:_________________________Typhon Encounter #: _____________________Comprehensive:____Focused:____S: SUBJECTIVE DATACC:What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.HPI: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:This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.ALLERGIESState the offending medication/food and the reactions.MEDICATIONSNames, dosages, and routes of administration along with indication of use.SHRelated 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.FHUse terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.HEALTH PROMOTION & MAINTENANCERequired for all SOAP notes:Immunizations, exercise, diet, etc. Remember to use theUnited States Clinical Preventative Services Task Force (USPSTF)for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.ROS(put N/A in sections not completed day of exam)ConstitutionalHeadEyesEars, Nose, Mouth, ThroatNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinaryMusculoskeletalIntegumentaryNeurologicalPsychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)EndocrineHematologic/LymphaticAllergic/ImmunologicOtherO: OBJECTIVE DATAVITALS:HR:RR:BP:Temp:SpO2%:Ht:Wt:BMI:Age:LMP:PAIN:PHYSICAL EXAM(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)General AppearanceHeadEyesENT, MouthNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinary Male· External Exam· Internal ExamGenitourinary Female· External Exam· Internal ExamMusculoskeletalIntegumentaryNeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/ImmunologicOtherA: ASSESSMENT AND DIAGNOSISDIAGNOSISICD-10 CODESPRIORITIZE DIAGNOSIS1.2.3.VISIT CODESCPT BILLING CODESDIAGNOSTICSPOC TESTINGTESTS REVIEWEDP: PLANACTIONS1.Diagnosis:Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.2.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:3.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:PREVENTITIVE(Used for comprehensive exams)Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.FOLLOW UPSOAPNoteTemplate-Final281293.docxThis file is too large to display.View in new windowSOAPNoteTemplate-Final281293.docxThis file is too large to display.View in new windowSOAPNoteTemplate-Final281293.docxSOAP Note _______NU___:_________Herzing UniversityName:_________________________Typhon Encounter #: _____________________Comprehensive:____Focused:____S: SUBJECTIVE DATACC:What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.HPI: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:This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.ALLERGIESState the offending medication/food and the reactions.MEDICATIONSNames, dosages, and routes of administration along with indication of use.SHRelated 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.FHUse terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.HEALTH PROMOTION & MAINTENANCERequired for all SOAP notes:Immunizations, exercise, diet, etc. Remember to use theUnited States Clinical Preventative Services Task Force (USPSTF)for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.ROS(put N/A in sections not completed day of exam)ConstitutionalHeadEyesEars, Nose, Mouth, ThroatNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinaryMusculoskeletalIntegumentaryNeurologicalPsychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)EndocrineHematologic/LymphaticAllergic/ImmunologicOtherO: OBJECTIVE DATAVITALS:HR:RR:BP:Temp:SpO2%:Ht:Wt:BMI:Age:LMP:PAIN:PHYSICAL EXAM(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)General AppearanceHeadEyesENT, MouthNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinary Male· External Exam· Internal ExamGenitourinary Female· External Exam· Internal ExamMusculoskeletalIntegumentaryNeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/ImmunologicOtherA: ASSESSMENT AND DIAGNOSISDIAGNOSISICD-10 CODESPRIORITIZE DIAGNOSIS1.2.3.VISIT CODESCPT BILLING CODESDIAGNOSTICSPOC TESTINGTESTS REVIEWEDP: PLANACTIONS1.Diagnosis:Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.2.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:3.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:PREVENTITIVE(Used for comprehensive exams)Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.FOLLOW UPSOAPNoteTemplate-Final281293.docxThis file is too large to display.View in new windowSOAPNoteTemplate-Final281293.docxSOAP Note _______NU___:_________Herzing UniversityName:_________________________Typhon Encounter #: _____________________Comprehensive:____Focused:____S: SUBJECTIVE DATACC:What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.HPI: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:This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.ALLERGIESState the offending medication/food and the reactions.MEDICATIONSNames, dosages, and routes of administration along with indication of use.SHRelated 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.FHUse terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.HEALTH PROMOTION & MAINTENANCERequired for all SOAP notes:Immunizations, exercise, diet, etc. Remember to use theUnited States Clinical Preventative Services Task Force (USPSTF)for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.ROS(put N/A in sections not completed day of exam)ConstitutionalHeadEyesEars, Nose, Mouth, ThroatNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinaryMusculoskeletalIntegumentaryNeurologicalPsychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)EndocrineHematologic/LymphaticAllergic/ImmunologicOtherO: OBJECTIVE DATAVITALS:HR:RR:BP:Temp:SpO2%:Ht:Wt:BMI:Age:LMP:PAIN:PHYSICAL EXAM(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)General AppearanceHeadEyesENT, MouthNeckCardiovascular/Peripheral VascularRespiratoryBreastGastrointestinalGenitourinary Male· External Exam· Internal ExamGenitourinary Female· External Exam· Internal ExamMusculoskeletalIntegumentaryNeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/ImmunologicOtherA: ASSESSMENT AND DIAGNOSISDIAGNOSISICD-10 CODESPRIORITIZE DIAGNOSIS1.2.3.VISIT CODESCPT BILLING CODESDIAGNOSTICSPOC TESTINGTESTS REVIEWEDP: PLANACTIONS1.Diagnosis:Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.2.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:3.Diagnosis:Diagnostics Order:Therapeutic:Education:Consultation/Collaboration:PREVENTITIVE(Used for comprehensive exams)Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.FOLLOW UPSOAPNoteTemplate-Final281293.docxThis file is too large to display.View in new window12Bids(50)Dr. Ellen RMDr. Aylin JMProf Double REmily Clarefirstclass tutorDoctor.NamiraMiss Deannasherry proffMUSYOKIONES A+Dr ClovergrA+de plusPROF_ALISTERProWritingGuruDr. Everleigh_JKIsabella HarvardBrilliant GeekTeacher A+ WorkAshley EllieLarry Kellyabdul_rehman_Show All Bidsother Questions(10)PowerPoint presentation (using speaker notes for each slide) outlining the revenue cycle management process. Your presentation should include a discussion on value-based care models as introduced by the Centers for Medicare and Medicaid Services (CMS)ETC W 6 AWeek 14 – Executive Practical Connection AssignmentFINAL PROJECTreconstruction ; what the black man wantsData Collection/AnalysisHirstate the principlePlease helpHR

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