NGR6002C – & Advanced Health Assessment

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Home>Homework Answsers>Nursing homework helpnursingPlease do not forget to add analysis or culture!!!5 months ago15.02.202545Report issuefiles (2)SOAPNote3ComprehensiveSOAPonMensandWomensHealth.docxSOAPTemplateandRubric_Updated-1.docxSOAPNote3ComprehensiveSOAPonMensandWomensHealth.docxPlease follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!Do not forget to add analysis or culture!!!Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.· Upload a copy of your completed SOAP note.· Upload a copy of the evaluation & management score sheet.Case Study:A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination. She says that while she does not perform breast self-examination often, she thinks that this lump is new. She denies nipple discharge or breast pain, although the lump is mildly tender on palpation. She has never noticed any breast masses previously and has never had a mammogram. She has no personal or family history of breast disease. She takes oral contraceptive pills (OCPs) regularly, but no other medications. She does not smoke cigarettes or drink alcohol Links to an external site.. She has never been pregnant. On examination, she is a well-appearing, somewhat anxious, and thin woman. Her vital signs are within normal limits. On breast examination, in the lower outer quadrant of the right breast, there is a 2-cm, firm, well-circumscribed, freely mobile mass without overlying erythema that is mildly tender to palpation. There is no skin dimpling, retraction, or nipple discharge. While no other discrete breast masses are palpable, the bilateral breast tissue is noted to be firm and glandular throughout. There is no evidence of axillary, supraclavicular, or cervical lymphadenopathy. The remainder of her physical examination is unremarkable.NGR6002C – SOAP Note 2 – 4 Rubric (1)NGR6002C – SOAP Note 2 – 4 Rubric (1)CriteriaRatingsPtsThis criterion is linked to a Learning OutcomeSubjective1-Subjective section should include:
a-Chief complaint (CC)
b-History of present illness (HPI)- All 7
attributes (location, quality, quantity or severity,
timing including onset, frequency, and duration,
setting in which it occurs, aggravating or
relieving factors, and associated symptoms)
c-Past history (Medical, Surgical,
Obstetric/Gynecology, Psychiatric)
d-family history (3 generation pedigree of first-
degree relatives, i.e. parents, siblings, children)
e. Personal and social history (i.e. sexual history
5p’s)
f. Review of systems (ROS, pertinent positives
and/or negatives)
g. Developmentally appropriate-i.e.
developmental history if peds, functional
assessment and/or dementia screen if elderly
a-Identified and collected the necessary data
b-Categorized and organized data using the
appropriate format
c-Incorporated all pertinent data/facts
d- Used proper documentation and proper billing
code
e- PATIENT’S CULTURE MUST BE NOTED0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomeObjective1-Objective section should include:
a. General survey
b. Vital Signs (including BMI and growth
chart if applicable)
c. All other necessary body systems
d. Diagnostic test if available
a. Identified and collected the necessary data
b. Categorized and organized data using the
appropriate format
c.Incorporated all pertinent data/facts
d. Used proper documentation and billing
code0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomeAssessment1- Identified correct diagnosis, ICD-10 code, and
correct differential diagnosis
a-Filtered relevant data from irrelevant data
b.-Interpreted relationships/patterns among data
(e.g., noted trends)
c.Integrated information to arrive at diagnosis
d.Identified risk factors
d. Used proper documentation0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomePlan Analysisa-Recommended an appropriate plan for each
problem
b-Included recommendations for non-drug and
drug therapy
c-Included recommendations for monitoring
d- Included health education
e- Included followup & referrals
f- include cultural considerations of patient care
Incorporate the patient’s culture on the
demographic section on SOAP notes.0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomeFormat1- APA
2- References Current (atleast two references,
one of which needs to be uptodate and the other
a clinical practice guideline from a peer
reviewed journal article or national organization
such as AAFP, ACOG, USPSTF)
3- Writing clear, concise0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsTotal Points: 1PreviousNextSOAPTemplateandRubric_Updated-1.docxThis file is too large to display.View in new windowSOAPTemplateandRubric_Updated-1.docxThis file is too large to display.View in new windowSOAPNote3ComprehensiveSOAPonMensandWomensHealth.docxPlease follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!Do not forget to add analysis or culture!!!Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.· Upload a copy of your completed SOAP note.· Upload a copy of the evaluation & management score sheet.Case Study:A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination. She says that while she does not perform breast self-examination often, she thinks that this lump is new. She denies nipple discharge or breast pain, although the lump is mildly tender on palpation. She has never noticed any breast masses previously and has never had a mammogram. She has no personal or family history of breast disease. She takes oral contraceptive pills (OCPs) regularly, but no other medications. She does not smoke cigarettes or drink alcohol Links to an external site.. She has never been pregnant. On examination, she is a well-appearing, somewhat anxious, and thin woman. Her vital signs are within normal limits. On breast examination, in the lower outer quadrant of the right breast, there is a 2-cm, firm, well-circumscribed, freely mobile mass without overlying erythema that is mildly tender to palpation. There is no skin dimpling, retraction, or nipple discharge. While no other discrete breast masses are palpable, the bilateral breast tissue is noted to be firm and glandular throughout. There is no evidence of axillary, supraclavicular, or cervical lymphadenopathy. The remainder of her physical examination is unremarkable.NGR6002C – SOAP Note 2 – 4 Rubric (1)NGR6002C – SOAP Note 2 – 4 Rubric (1)CriteriaRatingsPtsThis criterion is linked to a Learning OutcomeSubjective1-Subjective section should include:
a-Chief complaint (CC)
b-History of present illness (HPI)- All 7
attributes (location, quality, quantity or severity,
timing including onset, frequency, and duration,
setting in which it occurs, aggravating or
relieving factors, and associated symptoms)
c-Past history (Medical, Surgical,
Obstetric/Gynecology, Psychiatric)
d-family history (3 generation pedigree of first-
degree relatives, i.e. parents, siblings, children)
e. Personal and social history (i.e. sexual history
5p’s)
f. Review of systems (ROS, pertinent positives
and/or negatives)
g. Developmentally appropriate-i.e.
developmental history if peds, functional
assessment and/or dementia screen if elderly
a-Identified and collected the necessary data
b-Categorized and organized data using the
appropriate format
c-Incorporated all pertinent data/facts
d- Used proper documentation and proper billing
code
e- PATIENT’S CULTURE MUST BE NOTED0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomeObjective1-Objective section should include:
a. General survey
b. Vital Signs (including BMI and growth
chart if applicable)
c. All other necessary body systems
d. Diagnostic test if available
a. Identified and collected the necessary data
b. Categorized and organized data using the
appropriate format
c.Incorporated all pertinent data/facts
d. Used proper documentation and billing
code0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomeAssessment1- Identified correct diagnosis, ICD-10 code, and
correct differential diagnosis
a-Filtered relevant data from irrelevant data
b.-Interpreted relationships/patterns among data
(e.g., noted trends)
c.Integrated information to arrive at diagnosis
d.Identified risk factors
d. Used proper documentation0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomePlan Analysisa-Recommended an appropriate plan for each
problem
b-Included recommendations for non-drug and
drug therapy
c-Included recommendations for monitoring
d- Included health education
e- Included followup & referrals
f- include cultural considerations of patient care
Incorporate the patient’s culture on the
demographic section on SOAP notes.0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomeFormat1- APA
2- References Current (atleast two references,
one of which needs to be uptodate and the other
a clinical practice guideline from a peer
reviewed journal article or national organization
such as AAFP, ACOG, USPSTF)
3- Writing clear, concise0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsTotal Points: 1PreviousNextSOAPTemplateandRubric_Updated-1.docxThis file is too large to display.View in new windowSOAPNote3ComprehensiveSOAPonMensandWomensHealth.docxPlease follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!Do not forget to add analysis or culture!!!Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.· Upload a copy of your completed SOAP note.· Upload a copy of the evaluation & management score sheet.Case Study:A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination. She says that while she does not perform breast self-examination often, she thinks that this lump is new. She denies nipple discharge or breast pain, although the lump is mildly tender on palpation. She has never noticed any breast masses previously and has never had a mammogram. She has no personal or family history of breast disease. She takes oral contraceptive pills (OCPs) regularly, but no other medications. She does not smoke cigarettes or drink alcohol Links to an external site.. She has never been pregnant. On examination, she is a well-appearing, somewhat anxious, and thin woman. Her vital signs are within normal limits. On breast examination, in the lower outer quadrant of the right breast, there is a 2-cm, firm, well-circumscribed, freely mobile mass without overlying erythema that is mildly tender to palpation. There is no skin dimpling, retraction, or nipple discharge. While no other discrete breast masses are palpable, the bilateral breast tissue is noted to be firm and glandular throughout. There is no evidence of axillary, supraclavicular, or cervical lymphadenopathy. The remainder of her physical examination is unremarkable.NGR6002C – SOAP Note 2 – 4 Rubric (1)NGR6002C – SOAP Note 2 – 4 Rubric (1)CriteriaRatingsPtsThis criterion is linked to a Learning OutcomeSubjective1-Subjective section should include:
a-Chief complaint (CC)
b-History of present illness (HPI)- All 7
attributes (location, quality, quantity or severity,
timing including onset, frequency, and duration,
setting in which it occurs, aggravating or
relieving factors, and associated symptoms)
c-Past history (Medical, Surgical,
Obstetric/Gynecology, Psychiatric)
d-family history (3 generation pedigree of first-
degree relatives, i.e. parents, siblings, children)
e. Personal and social history (i.e. sexual history
5p’s)
f. Review of systems (ROS, pertinent positives
and/or negatives)
g. Developmentally appropriate-i.e.
developmental history if peds, functional
assessment and/or dementia screen if elderly
a-Identified and collected the necessary data
b-Categorized and organized data using the
appropriate format
c-Incorporated all pertinent data/facts
d- Used proper documentation and proper billing
code
e- PATIENT’S CULTURE MUST BE NOTED0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomeObjective1-Objective section should include:
a. General survey
b. Vital Signs (including BMI and growth
chart if applicable)
c. All other necessary body systems
d. Diagnostic test if available
a. Identified and collected the necessary data
b. Categorized and organized data using the
appropriate format
c.Incorporated all pertinent data/facts
d. Used proper documentation and billing
code0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomeAssessment1- Identified correct diagnosis, ICD-10 code, and
correct differential diagnosis
a-Filtered relevant data from irrelevant data
b.-Interpreted relationships/patterns among data
(e.g., noted trends)
c.Integrated information to arrive at diagnosis
d.Identified risk factors
d. Used proper documentation0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomePlan Analysisa-Recommended an appropriate plan for each
problem
b-Included recommendations for non-drug and
drug therapy
c-Included recommendations for monitoring
d- Included health education
e- Included followup & referrals
f- include cultural considerations of patient care
Incorporate the patient’s culture on the
demographic section on SOAP notes.0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsThis criterion is linked to a Learning OutcomeFormat1- APA
2- References Current (atleast two references,
one of which needs to be uptodate and the other
a clinical practice guideline from a peer
reviewed journal article or national organization
such as AAFP, ACOG, USPSTF)
3- Writing clear, concise0.2 to >0.15 ptsExemplary0.15 to >0.1 ptsProficient0.1 to >0.0 ptsNovice0 ptsDeveloping0.2 ptsTotal Points: 1PreviousNextSOAPTemplateandRubric_Updated-1.docxThis file is too large to display.View in new window12Bids(65)PROVEN STERLINGMiss DeannaDr. Ellen RMEmily ClareMathProgrammingDr. Aylin JMMISS HILLARY A+Dr Michelle Ellaabdul_rehman_Doctor.NamiraFortifiedSTELLAR GEEK A+WIZARD_KIMProWritingGuruYoung NyanyaProf. TOPGRADEgrA+de plusProf Double RDr. Adeline Zoefirstclass tutorShow All Bidsother Questions(10)DQFINC Investments – Investment Policy StatementTomImagine that you are explaining the threats of Social Engineering to the Corporate Entity to a nontechnical audience.For synco_solutions OnlyBUS 500 Module 1 Discussionnyamaimuletype of market structure does AutoEdgeSCHOLARSHIP ESSAY12 question of math

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