BM week 6 soap
Home>Homework Answsers>Nursing homework helpnursing researchnursingBM 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(50)Dr. Ellen RMDr. Aylin JMProf Double REmily Clarefirstclass tutorDoctor.NamiraMiss DeannaMUSYOKIONES A+Dr ClovergrA+de plusSheryl HoganPROF_ALISTERProWritingGuruDr. Everleigh_JKIsabella HarvardBrilliant GeekTeacher A+ WorkAshley EllieLarry Kellyabdul_rehman_Show All Bidsother Questions(10)E19-8B (Two Temporary Differences, One Rate, 3 Years)Tipper Company has two temporary differences between its income tax expense and income taxes payable. The following information is available. 2014 2015 2016 Pretax financial income $225,000 $268,000 $Network Infrastructure and SecurityE18-21B (Gross Profit Calculations and Repossessed Merchandise)Duke Corporation appropriately uses the installment-sales method of accounting. The following data were obtained for the years 2014 and 2015. Duke did not make any installment sales prior to 2CALCULUS CLASSCan i get this homework assignment done? Student’s Self-Service Website for Mobile DevicesAcademic Integrityreply questionbiology 101 readingTritechI need these converted to income statement and balance sheet? M&D Inc Adjusted Trial Balance12/31/2014 Income StatementBalance Sheet Account DebitCredit DebitCreditDebitCredit 15200 Cash 15
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