Loading...

Messages

Proposals

Stuck in your homework and missing deadline? Get urgent help in $10/Page with 24 hours deadline

Get Urgent Writing Help In Your Essays, Assignments, Homeworks, Dissertation, Thesis Or Coursework & Achieve A+ Grades.

Privacy Guaranteed - 100% Plagiarism Free Writing - Free Turnitin Report - Professional And Experienced Writers - 24/7 Online Support

Skin soap note

07/01/2021 Client: saad24vbs Deadline: 7 Days

Comprehensive SOAP Template


Patient Initials: _______ Age: _______ Gender: _______


Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.


O = onset of symptom (acute/gradual)


L= location


D= duration (recent/chronic)


C= character


A= associated symptoms/aggravating factors


R= relieving factors


T= treatments previously tried – response? Why discontinued?


S= severity


SUBJECTIVE DATA: Include what the patient tells you, but organize the information.


Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.


History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list:


1. Location


2. Quality


3. Quantity or severity


4. Timing, including onset, duration, and frequency


5. Setting in which it occurs


6. Factors that have aggravated or relieved the symptom


7. Associated manifestations


Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.


Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.


Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations., and


Past Surgical History (PSH): Include dates, indications, and types of operations.


Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and. risky sexual behaviors.


Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.


Immunization History: Include last Tdap, Flu, pneumonia, etc.


Significant Family History: Include history of parents, grandparents, siblings, and children.


Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.


Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text


General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.


HEENT:


Neck:


Breasts:


Respiratory:


Cardiovascular/Peripheral Vascular:


Gastrointestinal:


Genitourinary:


Musculoskeletal:


Psychiatric:


Neurological:


Skin: Hematologic:


Endocrine:


Allergic/Immunologic:


OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam.. Do not use “WNL” or “normal.” You must describe what you see.


Physical Exam:


Vital signs: Include vital signs, ht, wt, and BMI. Pulse Ox, Pain level.


General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things.


HEENT:


Neck:


Chest


Lungs:


Heart


Peripheral Vascular: Abdomen:


Genital/Rectal:


Musculoskeletal:


Neurological:


Skin:


Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses IF YOU ALREADY HAVE RESULTS.


ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.


PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.


Treatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.


Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.


Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.


REFLECTION: Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? This is worth 25 points!


References: Should use two peer-reviewed journal articles or references to support your reflection and differentials as well as any textbooks used.


© 2014 Laureate Education, Inc. Page 3 of 3

Homework is Completed By:

Writer Writer Name Amount Client Comments & Rating
Instant Homework Helper

ONLINE

Instant Homework Helper

$36

She helped me in last minute in a very reasonable price. She is a lifesaver, I got A+ grade in my homework, I will surely hire her again for my next assignments, Thumbs Up!

Order & Get This Solution Within 3 Hours in $25/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 3 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 6 Hours in $20/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 6 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 12 Hours in $15/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 12 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

6 writers have sent their proposals to do this homework:

Homework Guru
Helping Hand
University Coursework Help
Top Essay Tutor
Writer Writer Name Offer Chat
Homework Guru

ONLINE

Homework Guru

Hi dear, I am ready to do your homework in a reasonable price and in a timely manner.

$102 Chat With Writer
Helping Hand

ONLINE

Helping Hand

I am an Academic writer with 10 years of experience. As an Academic writer, my aim is to generate unique content without Plagiarism as per the client’s requirements.

$100 Chat With Writer
University Coursework Help

ONLINE

University Coursework Help

Hi dear, I am ready to do your homework in a reasonable price.

$102 Chat With Writer
Top Essay Tutor

ONLINE

Top Essay Tutor

I have more than 12 years of experience in managing online classes, exams, and quizzes on different websites like; Connect, McGraw-Hill, and Blackboard. I always provide a guarantee to my clients for their grades.

$105 Chat With Writer

Let our expert academic writers to help you in achieving a+ grades in your homework, assignment, quiz or exam.

Similar Homework Questions

Write the chemical equation for the ionic reaction between na2s and agno3 . - Discussion forum - What is the major output of service strategy - Short essays - What does me gusta mean - Difference between adn and bsn scope of practice - Marketing management russ winer ravi dhar - Save my exams physics - Acc100 aleks - Gta san andreas madd dogg mission glitch fix - CLP Group ESG and effect on valuation - Talking electronics pic projects - W8PAD530 - The universe next door - Explain the importance of establishing credibility for business communications - Role development in professional nursing practice w bind in access - Gippsland tafe yallourn campus - Discussion - Td o connell wichita ks - Intercultural Communication, Cultural Intelligence, and the Great Commission - Using technology to motivate and deliver curriculum to diverse learners in a personalized manner - The conceptual approach to independence requires that there is: - Brinch hansen method lateral pile capacity - Coconut crab amelia earhart - Mcminn book review - Haltech platinum sport 1000 price - Guided reading activity 5 3 dying and death answers - Miss tutor - Denver airport case study project management - Reading and Summarizing this source - Kvl and kcl practice problems pdf - Chapter 7 Discussion - Interpretative level of comprehension - Essay - The kite runner themes - Movie Noah, think writing ( no summarize) - The hedgehog and the fox pdf - Nanda nursing diagnosis list 2020 - Liverpool university open days - Feast watson tung oil - Bishops stortford newspaper obituaries - Mental status exam thought content - Which of the following is the correct definition of conduction - Recreation and wellness intranet project gantt chart - R programming - Artificial Intelligence - Formal appeal letter template - Logical Fallacies and Criminal Justice - 700 word discussion: Complexity is increasing as new technologies are emerging every day. This complexity impacts human experiences. Organizations are turning to digitally enabled solutions to assist with the emergence of digitalization. - Project Mgmt Process - Reflection, Discussion and Assignment - Discussion post - Sandra's case - Tools - Themes in god's bits of wood - Legal research - Creation account from genesis 1 2 powerpoint - Fremantle rebels softball club - Registry analysis in digital forensics - Sap sd resume pdf - 16 700 in scientific notation - Bio rad qc net - 5012_ASS 2 # DRAFT 1 # ASSESSMENT 2 Assessment 2 Instructions: Branding Presentation # MBA # FLEXPAH CAPELLA - Pretest and posttest research design - +91/*//*9928097710 lost lovE back solution Astrologer in IndORE , lucknOw - Xenonstack wikipedia - How to create football field chart in excel - Partial income statement discontinued operations - 221 mill street lake wendouree - How to cite google maps - Rm cobol compiler free download - Robotics on the Battlefield - Feast watson mastertouch wipe on poly - Chemistry - Accounting theory - Hampshire teaching payslips online - Process financial transactions and extract interim reports pdf - H2o extreme water sports - 1o mins quiz for econ - What is market value of a bond - Simnet excel project 6 6 - Social statistics for a diverse society 9th edition - Aziz rahman rahman ravelli - Evaluate your style with The pelle pelle jackets! - Homework computer - Ikea self service concept - Sailing to byzantium context - Energizer compact charger 12h - Climate change persuasive speech outline - Wk 5, IOP/470: Developing Transnational Groups - Air flows steadily in a pipe at - 7 Discussion Board: Evolution, Malaria, and Mosquitoes - Msds sheet for wd-40 - Long service leave sa - Accounting cycle project - Assignment 7 - Assignment - What is the rational approach - Carol ann duffy poetry collections - 5 computer discussions due in 24 hours - Pob 6.01 mba fi85 student worksheets answer key