SOAP Note Template Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor Past Medical History • Major/Chronic Illnesses____________________________________________________ • Trauma/Injury ___________________________________________________________ • Hospitalizations __________________________________________________________ Past Surgical History___________________________________________________________ Medications: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Family […]
Episodic/Focused SOAP Note Exemplar Focused SOAP Note for a patient with chest pain S. CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of […]
Tympanic Membrane and Thyroid Gland Week 8 Using the South University Online Library or the Internet, research the tympanic membrane and the thyroid gland. Based on your findings, create a 5- to 6-page Microsoft Word document that includes: Information about a minimum of two health assessment histories. The possible findings for the tympanic membrane. Information […]
Week 2: Respiratory Clinical Case APN Click here to download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care. Visit the online library […]
Assignment: Assessing, Diagnosing, and Treating Musculoskeletal and Neurologic Disorders Consider the example of Sue from the case study in Chapter 13 of your textbook: Sue is a 68-year-old healthy woman with no significant medical history. She is in the office today with complaint of intractable nausea and vomiting for the past 5 weeks with an […]
Focused SOAP Note Student’s Name Institutional Affiliation Course Professor’s Name Date Patient Information: J, 71, F, Race S (subjective) CC (chief complaint): Fatigue, thinning hair, and dry skin. HPI (history of present illness): Ms. Juggenmeir is a 71-year-old Female who comes into your office with concerns of fatigue and dry skin. She is a retired […]
WEEK 7: Assignment: Assessing, Diagnosing, and Treating Abdominal, Urological, and Gynecological Disorders Accurate history taking of abdominal, urological, and gynecological complaints is essential for completing an assessment of the older adult. For this Assignment, as you examine this week’s patient case study, consider how you might evaluate and treat older adult patients who present with […]
resources Reuben, D., Herr, K. A., Pacala, J. T., Pollock, B. G., Potter, J. F., & Semla, T. P. (2020). Respiratory diseases. In Geriatrics at your fingertips 2020 (22nd ed., pp. 321–339). American Geriatrics Society. USCD School of Medicine. (2018). USCD’s practical guide to clinical medicine. https://meded.ucsd.edu/clinicalmed/introduction.htm You may also wish to access the following […]
Resources needed on some questions and week 4 assignment Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Head, neck, and face disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 127–151). F. A. Davis. Goldberg, C. (2018b). The eye exam. In C. Goldberg, Practical guide to clinical medicine. Regents of […]
Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. HPI: This is the symptom analysis section of your note. Thorough documentation in this section is […]
