4 soaps needed RW: 4 soaps needed RW | Nursing

Clinical Requirement:

4 soaps needed RW AGPCSOAPNoteAssignmentInstructions.pdf 1 SOAP Note Assignment Instructions Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review. Sections of the SOAP note should be addressed if they are pertinent to the presenting chief complaint. Typhon Encounter #: Type of Note: Focused or Comprehensive Subjective (S): CC: chief complaint - 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: Who is the historian? Is the historian reliable? History of Present Illness - 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] Past medical history (PMH) - This should include illness/diagnosis, conditions, traumas, hospitalizations, and surgical history that is pertinent to the visit. Include dates if possible. Reproductive history: GTPAL, STIs, prenatal care, LMP, contraceptive methods, sexual and menstrual history. Include dates if possible. Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, routes, frequency, and indications. Social history: Related 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. Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Health Maintenance/Promotion - Required for all SOAP notes: Immunizations, exercise, diet, screening, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age-appropriate indicators, Healthy People 2030, and Centers for Disease Control and Prevention (CDC). This should reflect patient’s current recommendations. Up to date on health maintenance/promotion will NOT be accepted. Requires references. Review of systems (ROS) – • [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when conducting your ROS to make sure you have not missed any important symptoms, 2 particularly in areas that you have not already thoroughly explored while discussing the history of present illness.] You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic or follow-up visits (focused note) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. As opposed to a comprehensive visit which would address each system. Perform either a focused or comprehensive ROS based on the visit type. General: May include if patient has had a fever, chills, fatigue, malaise, etc. Skin: HEENT: head, eyes, ears, nose, and throat Neck: Breast: CV: cardiovascular Resp: respiratory GI: gastrointestinal GYN: gynecologic GU: genito-urinary PV: peripheral vascular MSK: musculoskeletal Neuro: neurological Endo: endocrine Psych: Objective (O): Physical exam (PE) – • [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection] Perform either a focused or comprehensive exam based on the visit type. This area should confirm your findings related to the diagnosis. For acute episodic or follow-up visits (focused) you may be omitting certain areas such as GYN, Rectal, Abd, etc. While a comprehensive visit will exam each area. Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the 3 same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory. Gen: general statement of appearance if there is any acute distress. VS: vital signs, height and weight, BMI Skin: HEENT: head, eyes, ears, nose, and throat Neck: Breast: CV: cardiovascular Resp: respiratory GI: gastrointestinal GU: genito-urinary Gyn: gynecologic PV: peripheral vascular MSK: musculoskeletal Neuro: neurological Endo: endocrine Psych: Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.). Assessment (A): This section should be a write-up utilizing your clinical decision-making with your diagnosis/diagnoses being supported by your ‘S’ data set and the ‘O’ data set. Pertinent positives and negatives must be found in the write-up. References required. Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis. Remember to include the appropriate ICD-10 code for each diagnosis. A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e., HTN-well managed on medication). Plan (P): Your plan should be supported by evidence-based guidelines with appropriate citations utilizing APA formatting. Your evidence-based plan may be deviated from your preceptor’s plan. Be sure to comment if there is a deviation in standard of care. 4 Document individual plans directly after each corresponding assessment (i.e., Diagnosis #1 found in the assessment should correlate with Plan #1). Address the following aspects (it should be separated out as listed below): Diagnostics: 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 the name of the medication, dose, route, quantity, and number of refills for any new or refilled medications. Educational: information clients need in order to address their health problems including the diagnosis itself, education on diagnostics, and therapies. 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. CPT: References Reference should support your patient’s management plan, including evidence-based practice, and utilize APA formatting. SOAPNoteTemplate-Final1_124176454.PDF SOAP Note _______ NU___:_________ Herzing University Name:_________________________ Typhon Encounter #: _____________________ Comprehensive:____Focused:____ S: SUBJECTIVE DATA CC: 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. ALLERGIES State the offending medication/food and the reactions. MEDICATIONS Names, dosages, and routes of administration along with indication of use. SH Related 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. FH Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. HEALTH PROMOTION & MAINTENANCE Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United 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) Constitutional Head Eyes Ears, Nose, Mouth, Throat Neck Cardiovascular/Peripheral Vascular Respiratory Breast Gastrointestinal https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations SOAP Note _______ NU___:_________ Herzing University Name:_________________________ Typhon Encounter #: _____________________ Comprehensive:____Focused:____ Genitourinary Musculoskeletal Integumentary Neurological Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) Endocrine Hematologic/Lymphatic Allergic/Immunologic Other O: OBJECTIVE DATA VITALS: 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 Appearance Head Eyes ENT, Mouth Neck Cardiovascular/Peripheral Vascular Respiratory Breast Gastrointestinal Genitourinary Male • External Exam • Internal Exam Genitourinary Female • External Exam • Internal Exam Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic SOAP Note _______ NU___:_________ Herzing University Name:_________________________ Typhon Encounter #: _____________________ Comprehensive:____Focused:____ Allergic/Immunologic Other A: ASSESSMENT AND DIAGNOSIS DIAGNOSIS ICD-10 CODES PRIORITIZE DIAGNOSIS 1. 2. 3. VISIT CODES CPT BILLING CODES DIAGNOSTICS POC TESTING TESTS REVIEWED P: PLAN ACTIONS 1. 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. SOAP Note _______ NU___:_________ Herzing University Name:_________________________ Typhon Encounter #: _____________________ Comprehensive:____Focused:____ 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 UP