NUR 514 Clinical Soap note 1

Clinical Requirement:

SOAPNote.docx A 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 up · Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings. · You must use the template provided. Turnitin will recognize the template and not score against it. SOAPNoteTemplate.docx SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics Chief Complaint (Reason for seeking health care) History of Present Illness (HPI) Allergies Review of Systems (ROS) General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Vital Signs Labs Medications Past Medical History Past Surgical History Family History Social History Health Maintenance/ Screenings Physical Examination General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Diagnosis Differential Diagnosis ICD 10 Coding Pharmacologic treatment plan Diagnostic/Lab Testing Education Anticipatory Guidance Follow up plan Prescription See Below (scroll down) References Grammar EA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature:____________________________________________________________ Signature (with appropriate credentials):_____________________________________ References (must use current evidence-based guidelines used to guide the care [Mandatory])