Laboratory Week 9: Soap Note #2 ADULT Wellness Check Up

 

Soap Note 1 “ADULT”  Wellness check up (10 points)

Follow the  Soap Note:

Use APA format and must include mia minimum of 2 Scholarly Citations.

Must use the sample templates for your soap note. Keep this template for when you start clinicals.

The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.

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Laboratory for Diagnosis, Symptom and Illness Management

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  8. Week 9: Soap Note #2 ADULT Wellness Check Up Due by 07/09/2022 at 11:59 pm
  9. What to Expect in a Wellness Visit (YouTube Video)

What to Expect in a Wellness Visit (YouTube Video)

Click https://youtu.be/zZFBCkn3EKA link to open resource. ◄ Discussion post on the • Topic: Discuss the importance of USPSTF Screening Recommendations in Primary Care. Jump to… Jump to… Announcements Q?/A Discussion Forum. Please ask your questions here. I am here to help you succeed. Syllabus Acknowledgement (Must be done by First Week of Class) MANDATORY (DO THIS FIRST) Syllabus MSN5600L 2022 SOAP NOTE template 2021-1 Typhon Setting Tutorial Introduce Yourself here 🙂 Ethics in a Nursing Program and in Practice. Student Verification ID (due 05/14/22) COMPLIO PACKAGES SELECTION ! Complio / American Databank Instructions COMPLIO 1ST TASK- open your account Due Date: 05/21/2022 (1% of final grade) COMPLIO 2nd TASK – Due date 07/16/2022 at 11:59pm (2% of final grade) FINAL COMPLIO TASK American Databank Clinical Requirements Due 07/23/2022 BY 11:59 PM (2% of final grade) Case Study 1 Case Study 2 Case Study 1 and 2 due 05/28/2022 at 11:59pm Clinical Diagnosis Quiz – 2% of final grade SOAP NOTE template 2022-1 SOAP NOTE Rubric SAMPLE SOAP Note Soap Note #1 Acute or Chronic Conditions USPSTF (YouTube Video) Please watch this video before attempting the quiz Second Diagnosis Quiz – Due Date 6/18/2022 at 11:59pm Case Study 3 Case Study 4 Case Study 3 & 4 3rd Diagnostic Quiz Discussion post on the • Topic: Discuss the importance of USPSTF Screening Recommendations in Primary Care. Wellness/Annual Check up SAMPLE SOAP NOTE (copy) Soap Note 1 Adult Wellness Check up Typhon Assignment 1 Due by 07/30/2022 at 23:59 Typhon Assignment 2 Due by 08/06/2022 by 11:59pm Typhon Assignment 3 Due by 08/20/2022 by 11:59pm Technical requirements Moodle Browser Configuration Wellness/Annual Check up SAMPLE SOAP NOTE (copy) ► You are logged in as Norma Hondal Alvarez (Log outMAIN_MSN5600L_R-V-FN2E_2022-GRAD2

Data retention summary

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

 

Soap Note # ____ Main Diagnosis ______________

 

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

1.

PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

 

Social History:

Sexual Orientation:

Nutrition History:

 

Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …

 

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

 

Objective Data:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

 

ASSESSMENT:

(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)

Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3)

 

 

 

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

1. –

1. –

Pharmacological treatment:

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

 

Follow-ups/Referrals

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).