soap note assignment to fill out

This is a soap note assignment to fill out. You need to do so research from the references above. Please i need conclusion paragraph when done. Please read the instructions carefully and answer the questions correctly. Can you do some research on the topic from the resources below. The references should be from 2016-2022 please.. Avoid plagiarism at all cost.

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This requires no pages. It requires you to filled out the soap note. You have stuff written in bolds, that’s for you to fill out and also do some researches using some references below and some good references of your choice. Please i also need an intext citation.

Skin Comprehensive SOAP Note

 

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:

Genitourinary:.

Musculoskeletal:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Mental examination:

Diagnostic result:

Patient education:

Treatment:

.

Diagnostic results:

Clubbing-

Radiology:

CXR :

ECG:

Normal sinus rhythmic movement:

Spirometry-

ASSESSMENT:

Differential Diagnosis (DDx):

Primary Diagnoses:

PLAN:

 

 

Patient

14F: CC: F/U feels the same, but more energetic

Meds: Pristiq 50mg, Vistaril 50mg

Dx: depression, anxiety, ADHD

Change: none

 

Learning Resources

soap note assignment to fill out Required Readings (click to expand/reduce)  

 

American Academy of Child and Adolescent Psychiatry. (2018). CPT code training module. https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/business_of_practice/cpt/2018_CPT_module_revised_March_2018.pdf

American Association of Nurse Practitioners. (2019). Discussion paper: Standards of practice for nurse practitioners. https://storage.aanp.org/www/documents/advocacy/position-papers/StandardsOfPractice.pdf

American Psychiatric Association. (2020). Coding and reimbursement. https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/coding-and-reimbursement

American Psychiatric Nurses Association. (2013). Population-focused nurse practitioner competencies. https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/Competencies/CompilationPopFocusComps2013.pdf

Note: Review the Psychiatric Mental Health Nurse Practitioner Competencies.

HSoft Corporation. (2020). Meditrek: Home. https://edu.meditrek.com/Default.html   

Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.  

International Council of Nurses. (2020). Guidelines on advanced practice nursing 2020. Author. https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf

The National Organization of Nurse Practitioner Faculties. (n.d.). Retrieved August 24, 2020, from https://www.nonpf.org/

The National Organization of Nurse Practitioner Faculties. (2017). Nurse practitioner core competencies content. https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/competencies/20170516_NPCoreCompsContentF.pdf

Walden University Academic Skills Center. (2017). Developing SMART goals. https://academicguides.waldenu.edu/ld.php?content_id=51901492

Walden University. (2020). College of Nursing practicum manual: Master of science in nursing (MSN) and post-master’s certificate programs. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments

Walden University Field Experience. (2020a). Field experience: College of Nursing.  https://academicguides.waldenu.edu/fieldexperience/son/home 

 

The patient log must include the following:

  • Date
  • Course
  • Clinical Faculty
  • Preceptor
  • Patient Number
  • Client Information
  • Visit Information
  • Practice Management
  • Diagnosis
  • Student Notes- Students must include a brief summary/synopsis of the patient visit—this does not need to be a SOAP note; however, the note needs to be sufficient to remember your patient encounter

 

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