Please *Education is very vital in the plan for this patient. Please include necessary education.
Please review the rubric and follow all the instructions provided for this order.
*Please submit this order on time. It is paramount.
The SOAP notes are not to be written in paragraph form, but just as you would write them in the chart. Please review the rubric and follow the instructions provided for this order. It is vital that you follow the instructions in the rubric to meet the criteria. *Kindly add if necessary thing that you think that are necessary to improve my grade that I might have missed or forgot to add. *Please use APA 7. *Please use SOAP and OLDCART format.
I have uploaded the patient reference to use.
Thank you for all you do.
Getting Started
Introduction
The ability to write accurate, concise soap notes is an integral skill for the advanced practice registered nurse (APRN). Professional documentation is the mechanism to communicate with other healthcare providers, support the level of billing for the service provided as well as provides legal protection for the APRN and organization.
Upon successful completion of this assignment you will be able to:
Write accurate, concise organized soap notes which accurately reflect the care provided.
Manage clients who have communicable disease, use complementary medicine, or have an environmental condition.
Resources
Patient notes from clinical setting
Instructions
Review the rubric to make sure you understand the criteria for earning your grade.
Write 2 focused soap notes from any patient you have seen during clinical in the recent past. Your soap notes must include the following:
Subjective: Subjective: CC, HPI, focused PMH (allergies, meds, surgeries, medical conditions, FMH, SH – only what is pertinent to the case) and ROS.
Objective: vitals, General statement, pertinent PE per the chief complaint and at least 2 bullet points per system. You will lose points if your bullet points include “normal, within normal limits or unremarkable”. You are expected to describe your findings.
Assessment: Diagnosis with 3 separate differentials, pertinent comorbid diagnoses stating controlled or uncontrolled. Please include your rationale for your choices.
Plan: medications, labs/imaging, referrals, education given, follow-up. If any items that have been listed do not apply to your patient, that is fine. Not every patient will have a referral or labs/imaging.
3. These are not to be the same soap notes that you place in Medatrax for your Medatrax assignment.
4. No references are required. The SOAP Notes are not to be written in paragraph form, but just as you would write them in the chart.
5. Submit both SOAP Notes to the Assignment 6.8 by the end of day seven of the workshop. You must include a cover sheet per APA guidelines.