Home>Homework Answsers>Nursing homework helpnursingnursing researchroch week 6 soap20 days ago11.06.202515Report issuefiles (1)SOAPNoteTemplate-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.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 UPBids(47)Dr. Ellen RMMISS HILLARY A+Dr. Aylin JMProf Double REmily Clarefirstclass tutorMiss Deannasherry proffMUSYOKIONES A+Dr ClovergrA+de plusSheryl HoganPROF_ALISTERpacesetters2121ProWritingGuruDr. Everleigh_JKIsabella HarvardBrilliant GeekTeacher A+ WorkAshley EllieShow All Bidsother Questions(10)HistoryNetworking Trends (Long) PaperEnglishThis discussion has 3 parts: What effective time management tools should managers use to make effective use of their time when it comes to coping with demands, constraints, and choices confronting them? What experience do you have with team building? Whunit3 fireessayMathDiscussion questionfor Michael Smith1 page discussion and 2 page paper both should be separate
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