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Need help with my Health & Medical question - I’m studying for my class.
A) Please fallow instruction. I need you to make up a soap note for a female patient with diagnoses of Chlamydia. Please fill out the template. I include the soap note template you must plug the information, the rubric to follow in separate attachments. I need you to provide the following: APA format with references at least no older than 5 years.
1)The Diagnosis ICD 10 code
2) 3 differential diagnoses with ICD 10 code.
3)Vital sign, BMI
4)Complete Chief patient compliant
5)Subjective Information
6)PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.
7)Complete Objective Information
8)Lab Tests
9)Allergies
10)Complete physical exam with critical elements related to subjective data.
11)Perform Assessment
12)Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
13)Create a Plan
14)Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.
15)Self-Assessment & Clinical Guidelines
16)Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.
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