wk7 problem focused soap note

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Home>Homework Answsers>Nursing homework help13 days ago22.06.202550Report issuefiles (1)Problemfocusedsoapnotetemplate.docxProblemfocusedsoapnotetemplate.docxProblem-focused SOAP Note FormatDemographic Data· Age, and gender (must be HIPAA compliant)Subjective· Chief Complaint (CC): A short statement about why they are there· History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment· Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance· Family Hx: any history of CA, DM, HTN, MI, CVA?· Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.· Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)Objective· Vital Signs· Physical findings listed by body systems, not paragraph form- Highlight abnormal findingsAssessment (the diagnosis)· At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each· Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanationPlan· Dx Plan (lab, x-ray)· Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)· Pt. Education, including specific medication teaching points· Referral/Follow-up· Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next dueReference· Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.Problemfocusedsoapnotetemplate.docxProblem-focused SOAP Note FormatDemographic Data· Age, and gender (must be HIPAA compliant)Subjective· Chief Complaint (CC): A short statement about why they are there· History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment· Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance· Family Hx: any history of CA, DM, HTN, MI, CVA?· Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.· Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)Objective· Vital Signs· Physical findings listed by body systems, not paragraph form- Highlight abnormal findingsAssessment (the diagnosis)· At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each· Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanationPlan· Dx Plan (lab, x-ray)· Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)· Pt. Education, including specific medication teaching points· Referral/Follow-up· Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next dueReference· Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.Bids(61)PROVEN STERLINGMiss DeannaDr. Ellen RMEmily ClareMathProgrammingDr. Aylin JMDr. Sarah BlakeMISS HILLARY A+Dr Michelle Ellaabdul_rehman_STELLAR GEEK A+ProWritingGuruWIZARD_KIMYoung NyanyaProf. TOPGRADEfirstclass tutorProf Double RDr. Adeline Zoesherry proffnicohwilliamShow All Bidsother Questions(10)analyzing a marketHistoryPSY100 Assignment wk8MAT510 & BUS520 Week 8 Discussioninformation security systems assignmentThis unit has focused on the uptake of carbon dioxide by photosynthetic organisms and its release during aerobic cellular respiration. Discuss…THANKYOUtwentyKIM WOODSSOC-320 Topic 4 DQ 1

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