Title: Documentation of problem based assessment of the neurological system. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of neurological system. Identify abnormal findings. Course Competency: Apply assessment techniques for the neurological and respiratory systems. Instructions: Content: Use of three sections: o Subjective o Objective o Actual […]
(Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name: Mr. DT Age: 68-year-old Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: PCN, Iodine Current Medications: • Atorvastatin tab […]
Grand Rounds Discussion: Complex Case Study Presentation Photo Credit: [RGtimeline]/[iStock / Getty Images Plus]/Getty Images This week you participate in the final of three clinical discussions called grand rounds. When it is your week to present, you will create a focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex […]
Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32 Comprehensive (Head-to-Toe) Physical Assessment Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32 these assessments, […]
Specific Instructions You are the group of Nurse Practitioners working at AGM Primary Care Medical Center. Develop the presentation of the Case Study as follows: 1. Discussion of assigned medical condition: a) Description 1) Pathophysiology 2) Etiology b) Clinical Manifestations 1) Red Flags 2. Case Study a) Create a hypothetical case of a patient who […]
Week 9 case study CASE STUDY 1: Headaches A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occur above the eyes and spreads through the nose, cheekbones, and jaw. The Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than […]
Assignment 4: Clinical Hour and Patient Logs Assignment Instructions: • I need 16 small individual psychotherapy clinical notes (one paragraph), each note should include: CC, small mental status, and progress achieved during the visit. Please review the below example, doesn’t have to exactly as the example but close enough. • Student Notes- Students must include […]
Initial Psychiatric SOAP Note Template There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting. Criteria Clinical Notes Informed Consent Informed consent given to […]
Week 9 Shadow Health Comprehensive SOAP Note Template Patient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): History of Present Illness (HPI): Medications: Allergies: Past Medical History (PMH): Past Surgical History (PSH): Sexual/Reproductive History: Personal/Social History: Health Maintenance: Immunization History: Significant Family History: Review of Systems: General: HEENT: Respiratory: Cardiovascular/Peripheral Vascular: Gastrointestinal: […]
Tympanic Membrane and Thyroid Gland HW 7 Tympanic Membrane and Thyroid Gland HW 7 Using the classroom resources or Online Library, research the tympanic membrane and the thyroid gland. In a Microsoft Word document of 4-5 pages formatted in APA style, address each of the following criteria. Two focused health assessment histories One assessment related […]
