NUR 612 Clinical SOAP Note 1

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Home>Homework Answsers>Nursing homework helpnursinga month ago31.05.202525Report issuefiles (3)ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docxSOAPNoteTemplate-1.docxSoapNoterubric.docxASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docxA SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.Instructions:SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:S=Subjective data: Patient’s Chief Complaint (CC).O=Objective data: Including client behavior, physical assessment, vital signs, and meds.A=Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P=Plan: Treatment, diagnostic testing, and follow upSOAPNoteTemplate-1.docxSOAP NOTE TEMPLATEReview the Rubric for more GuidanceDemographicsChief Complaint (Reason for seeking health care)History of Present Illness (HPI)AllergiesReview of Systems (ROS)General:HEENT:Neck:Lungs:CardioBreast:GI:M/F genital:GU:NeuroMusculo:Activity:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Vital SignsLabsMedicationsPast Medical HistoryPast Surgical HistoryFamily HistorySocial HistoryHealth Maintenance/ ScreeningsPhysical ExaminationGeneral:HEENT:Neck:Lungs:CardioBreast:GI:M/F genital:GU:NeuroMusculo:Activity:Psychosocial:Derm:DiagnosisDifferential DiagnosisICD 10 CodingPharmacologic treatment planDiagnostic/Lab TestingEducationAnticipatory GuidanceFollow up planPrescriptionSee Below (scroll down)ReferencesGrammarEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________ Refill: _________________No SubstitutionSignature:____________________________________________________________Signature (with appropriate credentials):_____________________________________References (must use current evidence-based guidelines used to guide the care [Mandatory])SoapNoterubric.docxDemographics1 to >0.8 ptsBegins with patient initials, age, race, ethnicity and gender (5 demographics)Chief Complaint (Reason for seeking health care)4 to >3 ptsIncludes a direct quote from patient about presenting problemHistory of the Present Illness (HPI)5 to >3 ptsIncludes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)Allergies2 to >1.5 ptsIncludes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)Review of Systems (ROS)2 to >1.5 ptsIncludes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.Labs4 to >2 ptsIncludes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)Past Medical History3 to >2 ptsIncludes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or currentPast Surgical History3 to >2 ptsIncludes, for each surgical procedure, the year of procedure and the indication for the procedureFamily History3 to >2 ptsIncludes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.Social History3 to >2 ptsIncludes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situationHealth Maintenance / Screenings3 to >2 ptsIncludes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening testsPhysical Examination15 to >8 ptsIncludes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaintDiagnosis5 to >3 ptsIncludes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)Differential Diagnosis5 to >3 ptsIncludes at least 3 differential diagnoses for the principal diagnosisPharmacologic treatment plan5 to >3 ptsIncludes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.Diagnostic / Lab Testing3 to >2 ptsIncludes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”Education3 to >2 ptsIncludes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their livesAnticipatory Guidance3 to >2 ptsIncludes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))Follow Up Plan2 to >1 ptsIncludes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)Prescription3 to >2 ptsPrescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentialsWriting Mechanics, Citations, and APA Style3 to >2 ptsEffectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.SoapNoterubric.docxDemographics1 to >0.8 ptsBegins with patient initials, age, race, ethnicity and gender (5 demographics)Chief Complaint (Reason for seeking health care)4 to >3 ptsIncludes a direct quote from patient about presenting problemHistory of the Present Illness (HPI)5 to >3 ptsIncludes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)Allergies2 to >1.5 ptsIncludes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)Review of Systems (ROS)2 to >1.5 ptsIncludes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.Labs4 to >2 ptsIncludes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)Past Medical History3 to >2 ptsIncludes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or currentPast Surgical History3 to >2 ptsIncludes, for each surgical procedure, the year of procedure and the indication for the procedureFamily History3 to >2 ptsIncludes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.Social History3 to >2 ptsIncludes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situationHealth Maintenance / Screenings3 to >2 ptsIncludes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening testsPhysical Examination15 to >8 ptsIncludes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaintDiagnosis5 to >3 ptsIncludes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)Differential Diagnosis5 to >3 ptsIncludes at least 3 differential diagnoses for the principal diagnosisPharmacologic treatment plan5 to >3 ptsIncludes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.Diagnostic / Lab Testing3 to >2 ptsIncludes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”Education3 to >2 ptsIncludes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their livesAnticipatory Guidance3 to >2 ptsIncludes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))Follow Up Plan2 to >1 ptsIncludes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)Prescription3 to >2 ptsPrescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentialsWriting Mechanics, Citations, and APA Style3 to >2 ptsEffectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docxA SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.Instructions:SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:S=Subjective data: Patient’s Chief Complaint (CC).O=Objective data: Including client behavior, physical assessment, vital signs, and meds.A=Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P=Plan: Treatment, diagnostic testing, and follow upSOAPNoteTemplate-1.docxSOAP NOTE TEMPLATEReview the Rubric for more GuidanceDemographicsChief Complaint (Reason for seeking health care)History of Present Illness (HPI)AllergiesReview of Systems (ROS)General:HEENT:Neck:Lungs:CardioBreast:GI:M/F genital:GU:NeuroMusculo:Activity:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Vital SignsLabsMedicationsPast Medical HistoryPast Surgical HistoryFamily HistorySocial HistoryHealth Maintenance/ ScreeningsPhysical ExaminationGeneral:HEENT:Neck:Lungs:CardioBreast:GI:M/F genital:GU:NeuroMusculo:Activity:Psychosocial:Derm:DiagnosisDifferential DiagnosisICD 10 CodingPharmacologic treatment planDiagnostic/Lab TestingEducationAnticipatory GuidanceFollow up planPrescriptionSee Below (scroll down)ReferencesGrammarEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________ Refill: _________________No SubstitutionSignature:____________________________________________________________Signature (with appropriate credentials):_____________________________________References (must use current evidence-based guidelines used to guide the care [Mandatory])SoapNoterubric.docxDemographics1 to >0.8 ptsBegins with patient initials, age, race, ethnicity and gender (5 demographics)Chief Complaint (Reason for seeking health care)4 to >3 ptsIncludes a direct quote from patient about presenting problemHistory of the Present Illness (HPI)5 to >3 ptsIncludes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)Allergies2 to >1.5 ptsIncludes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)Review of Systems (ROS)2 to >1.5 ptsIncludes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.Labs4 to >2 ptsIncludes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)Past Medical History3 to >2 ptsIncludes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or currentPast Surgical History3 to >2 ptsIncludes, for each surgical procedure, the year of procedure and the indication for the procedureFamily History3 to >2 ptsIncludes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.Social History3 to >2 ptsIncludes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situationHealth Maintenance / Screenings3 to >2 ptsIncludes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening testsPhysical Examination15 to >8 ptsIncludes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaintDiagnosis5 to >3 ptsIncludes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)Differential Diagnosis5 to >3 ptsIncludes at least 3 differential diagnoses for the principal diagnosisPharmacologic treatment plan5 to >3 ptsIncludes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.Diagnostic / Lab Testing3 to >2 ptsIncludes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”Education3 to >2 ptsIncludes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their livesAnticipatory Guidance3 to >2 ptsIncludes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))Follow Up Plan2 to >1 ptsIncludes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)Prescription3 to >2 ptsPrescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentialsWriting Mechanics, Citations, and APA Style3 to >2 ptsEffectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docxA SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.Instructions:SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:S=Subjective data: Patient’s Chief Complaint (CC).O=Objective data: Including client behavior, physical assessment, vital signs, and meds.A=Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P=Plan: Treatment, diagnostic testing, and follow upSOAPNoteTemplate-1.docxSOAP NOTE TEMPLATEReview the Rubric for more GuidanceDemographicsChief Complaint (Reason for seeking health care)History of Present Illness (HPI)AllergiesReview of Systems (ROS)General:HEENT:Neck:Lungs:CardioBreast:GI:M/F genital:GU:NeuroMusculo:Activity:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Vital SignsLabsMedicationsPast Medical HistoryPast Surgical HistoryFamily HistorySocial HistoryHealth Maintenance/ ScreeningsPhysical ExaminationGeneral:HEENT:Neck:Lungs:CardioBreast:GI:M/F genital:GU:NeuroMusculo:Activity:Psychosocial:Derm:DiagnosisDifferential DiagnosisICD 10 CodingPharmacologic treatment planDiagnostic/Lab TestingEducationAnticipatory GuidanceFollow up planPrescriptionSee Below (scroll down)ReferencesGrammarEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________ Refill: _________________No SubstitutionSignature:____________________________________________________________Signature (with appropriate credentials):_____________________________________References (must use current evidence-based guidelines used to guide the care [Mandatory])SoapNoterubric.docxDemographics1 to >0.8 ptsBegins with patient initials, age, race, ethnicity and gender (5 demographics)Chief Complaint (Reason for seeking health care)4 to >3 ptsIncludes a direct quote from patient about presenting problemHistory of the Present Illness (HPI)5 to >3 ptsIncludes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)Allergies2 to >1.5 ptsIncludes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)Review of Systems (ROS)2 to >1.5 ptsIncludes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.Labs4 to >2 ptsIncludes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)Past Medical History3 to >2 ptsIncludes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or currentPast Surgical History3 to >2 ptsIncludes, for each surgical procedure, the year of procedure and the indication for the procedureFamily History3 to >2 ptsIncludes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.Social History3 to >2 ptsIncludes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situationHealth Maintenance / Screenings3 to >2 ptsIncludes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening testsPhysical Examination15 to >8 ptsIncludes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaintDiagnosis5 to >3 ptsIncludes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)Differential Diagnosis5 to >3 ptsIncludes at least 3 differential diagnoses for the principal diagnosisPharmacologic treatment plan5 to >3 ptsIncludes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.Diagnostic / Lab Testing3 to >2 ptsIncludes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”Education3 to >2 ptsIncludes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their livesAnticipatory Guidance3 to >2 ptsIncludes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))Follow Up Plan2 to >1 ptsIncludes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)Prescription3 to >2 ptsPrescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentialsWriting Mechanics, Citations, and APA Style3 to >2 ptsEffectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.123Bids(47)PROVEN STERLINGMiss DeannaDr. Ellen RMEmily ClareDr. Aylin JMMISS HILLARY A+Dr Michelle Ellaabdul_rehman_STELLAR GEEK A+WIZARD_KIMProf Double RDr. Adeline Zoesherry proffPremiumIsabella HarvardMUSYOKIONES A+Dr CloverPROF_ALISTERgrA+de plusSheryl HoganShow All Bidsother Questions(10)ETH 125 Week 6 DQ 2ida-volatilaty- memory forensics2 pages on belowRouting assignment 4BIO 220 Laboratory Exercises – Part 1 & Part 2You have already compute sample parameters for the data.ECO 550 MIDTERM EXAM (PART 1 & 2) ALL CORRECTECON 550The question is belowI need a 4 pages essay to be done in 2 hours.

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