Our Services

Get 15% Discount on your First Order

MR unit 4 soap SOAP Note _____ NU_:_________ Herzing University

September 25, 2024

MR unit 4 soap

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
	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
	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. 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

>Nursing homework help

Share This Post

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Find a white-collar criminal case that has happened in the past 5 years (2018-2023), that is related to the types of white-collar crimes we have discussed.

Find a white-collar criminal case that has happened in the past 5 years (2018-2023), that is related to the types of white-collar crimes we have discussed. (education, religion, corporate, investment,

View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study. Document

View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study. Document the following for the family in the video using the Comprehensive Evaluation Note Template:

INSTRUCTIONS- · Answer the five (5) quiz questions below. Answer questions that · Provide an evidence-based rationale for each of your answers to

INSTRUCTIONS- · Answer the five (5) quiz questions below. Answer questions that · Provide an evidence-based rationale for each of your answers to the five (5) questions. · Provide a citation and matching reference is required from the course textbook for each of the five (5) rationales. Textbook name provide below

Select and describe the specific amenities that will help distinguish your hotel’s brand. Describe how the experience economy, service, and product will

Select and describe the specific amenities that will help distinguish your hotel’s brand. Describe how the experience economy, service, and product will be established. What type of management organization will your hotel possess? Why did you select this type of management organization? What type of security features will your hotel

Week 6 Imagine you teach in a regular education classroom of 25 students. Among them are 1 student who has a

Week 6 Imagine you teach in a regular education classroom of 25 students. Among them are 1 student who has a learning disability, 2 students with attention-deficit/hyperactivity disorder (ADHD), 1 English language learner (ELL) student, and 1 gifted student. Choose your preferred grade level for this class. Identify a content

· A separately link listed below this posting contains al list case studies. Choose a case study from the list and read the information

· A separately link listed below this posting contains al list case studies. Choose a case study from the list and read the information provided. Then read 5 crucial elements in conducting a crisis audit reading in this link: After summarizing the company’s situation, using the 5 elements provided, explain

find the attached documents below. The topic i choose that I want you to talk about is Dementia

What To Do Read the case study and answer the questions provided in the linked file. Please note: Your assignment will be graded based on how you apply

What To Do Read the case study and answer the questions provided in the linked file. Please note: Your assignment will be graded based on how you apply the information learned in class, thus your answers need to be thorough. Use complete sentences in response to the questions posed

Find a white-collar criminal case that has happened in the past 5 years (2018-2023), that is related to the types of white-collar crimes we have discussed.

help with informatic technology 1 Assessment 01 – Nursing Informatics in Health Care For this assessment, you will write a 4–5 page

help with informatic technology 1 Assessment 01 – Nursing Informatics in Health Care For this assessment, you will write a 4–5 page evidence-based proposal to support the need for a nurse informaticist in an organization who would focus on improving health care outcomes. Before you complete the detailed instructions in

Note: I have added most of the work. I need this corrected and edited properly. I have fixed the spacing for the foot notes. Improve as possible. I need

Note: I have added most of the work. I need this corrected and edited properly. I have fixed the spacing for the foot notes. Improve as possible. I need more sources and the biblography. Especially more Primary Sources.SUBJECT: The impact of the Fall of Afghanistan on US VeteransSubmit a 25-page

Description Saudi Electronic University College of Administrative and Financial Sciences E-commerce Department Student Name: Student ID: Course

Description Saudi Electronic University College of Administrative and Financial Sciences E-commerce Department Student Name: Student ID: Course Title: Management Information Course Code: MIS201 System Academic Year/ Semester: CRN: Instructor Name: Student Grade: Grade Level: Low/ Middle / High Saudi Electronic University College of Administrative and Financial Sciences Assignment of MIS201-

Description Academic Report Guideline(Co-op) The report should be submitted within two weeks after you finish your Co-op training Program. In

Description Academic Report Guideline(Co-op) The report should be submitted within two weeks after you finish your Co-op training Program. In addition, the report should be approximately 3000 – 4000, single –spaced and consider taking the following format General instructions for writing the final report: The report must be written in

Instructions are attached · Respond to at least two (2) peers · APA format · 100 words each reply Peer 1: Natalia When

Instructions are attached · Respond to at least two (2) peers · APA format · 100 words each reply Peer 1: Natalia When considering the ease of learning reversals in the symbolic matching-to-sample task for pigeons, it is essential to evaluate the principles of “common coding” or mediated generalization. These

attached Comment about this post: Achievement in adolescence level is quite important as it establishes a base for one’s attainment in the future.

attached Comment about this post: Achievement in adolescence level is quite important as it establishes a base for one’s attainment in the future. The main aspect consists of the fact that there is a distinction between a learning motivation (i.e., improving one’s skills) and a fearful motivation (i.e., to demonstrate

Yulia Gutsul T00434432 Module 5 Pre-observation interview

Yulia Gutsul T00434432 Module 5 Pre-observation interview The subject of this lesson is “Alphabet”. · At the end of the class, most students may: · Recognize words that are relevant to the letters of the specific alphabet. · Read the various letters of the alphabet. · Determine has given objects

Case Summary The school RN sees an 8-year-old male coming into the nursing office by his Phys Ed teaching with

Case Summary The school RN sees an 8-year-old male coming into the nursing office by his Phys Ed teaching with complaints of profuse sweating and confusion. The patient is currently afebrile. Objectives. ( More or less are possible) 1. Recognizing signs of hypoglycemia 2. Differentiate between hypo- and hyperglycemia 3.

Our Services

MR unit 4 soap SOAP Note _______ NU___:_________ Herzing University

Share This Post

Related Questions

Use Our 6 Free Tools

MR unit 4 soap SOAP Note _____ NU_:_________ Herzing University