please see attached

You are going to create a soap note about this patient here: D.W is a 29-year-old G2P1 female presents to the clinic with complaints of sharp, intermittent lower abdominal pain on the right side that started three days ago. She reports that the pain has gradually worsened and is now constant, radiating to her lower back. She also notes light vaginal spotting, which she initially thought was an irregular period, but it has continued for several days. The patient states that she has been feeling lightheaded and nauseous since this morning. Her last menstrual period (LMP) was six weeks ago, and she has a history of irregular cycles. She had a positive home pregnancy test one week ago but has not yet had her first prenatal visit. She denies passing clots, fever, chills, dysuria, or recent infections.

Her past obstetric history includes one prior full-term vaginal delivery without complications. She has no known history of sexually transmitted infections (STIs), pelvic inflammatory disease (PID), or previous ectopic pregnancy. However, she does report a prior laparoscopic appendectomy at age 22. The patient is sexually active in a monogamous relationship and has not been using contraception.

On physical examination, she appears slightly pale and uncomfortable but is alert and oriented. Her vital signs show mild tachycardia (HR: 102 bpm), normal blood pressure (110/70 mmHg), and normal temperature (98.6°F). A pelvic examination reveals mild cervical motion tenderness, significant right adnexal tenderness, and a slightly enlarged uterus. No significant vaginal bleeding is observed. I am attaching the template so you can develop one. In addition to that I am attaching my previous one so you can understand about the references and in text citations and per reviewed rationales. Instructions: 

nstructions:

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up . SOAP starts  Begins with patient initials, age, race, ethnicity and gender (5 demographics)  

Chief Complaint (Reason for seeking health care)

4 to >3 pts
Includes a direct quote from patient about presenting problem  

History of the Present Illness (HPI)

5 to >3 pts
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)  

Allergies

2 to >1.5 pts
Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)  

Review of Systems (ROS)

15 to >8 pts
Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”  

Vital Signs

2 to >1.5 pts
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)  

Labs

2 to >1.5 pts
Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.  

Medications

4 to >2 pts
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)  

Past Medical History

3 to >2 pts
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current  

Past Surgical History

3 to >2 pts
Includes, for each surgical procedure, the year of procedure and the indication for the procedure
 

Family History

3 to >2 pts
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.  

Social History

3 to >2 pts
Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation. 

Health Maintenance / Screenings

3 to >2 pts
Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests  

Physical Examination

15 to >8 pts
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint  

Diagnosis

5 to >3 pts
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) with in text citation 

Differential Diagnosis

5 to >3 pts
Includes at least 3 differential diagnoses for the principal diagnosis with in text citations  

ICD 10 Coding

3 to >2 pts
Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit  

Pharmacologic treatment plan

5 to >3 pts
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. AL L with in text citations- references.  

Diagnostic / Lab Testing

3 to >2 pts
Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”  

Education

3 to >2 pts
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.  

Anticipatory Guidance

3 to >2 pts
Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening)) all with in text citations and references  

Follow Up Plan

2 to >1 pts
Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)  

Prescription

3 to >2 pts
Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials

 

Writing Mechanics, Citations, and APA Style

3 to >2 pts
Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors. Include at least 6 References.

 

• Find a published research article on a topic relevant to your practice of an experiment where the researcher does not list any hypotheses.
•  Provide the purpose/objective/aim exactly as stated in the research article. If there are more than one hypothesis, provide only one to focus on.
  • Name the population being studied
  • Identify one independent variable (IV) and one dependent variable (DV)
  • Identify the level of measurement (nominal, ordinal, interval, ratio) for the DV and the type of variable (categorical or continuous).
• Step 1 in hypothesis testing is: Determine Hypotheses
  • Rewrite the purpose/objective/aim as a null hypothesis (Ho) in words and in an equation. See the handout posted to the initial announcement this week for how to write the null and alternative hypotheses for the inferential test used to test the DV.
  • Rewrite the null hypothesis as an alternative hypothesis (Ha) in words and an equation.
• Use information from the article to complete the rest of the steps in hypothesis testing:
  • Step 2: Propose an appropriate test. Find this information in the paragraph(s) right above the Results section. Table 7-1 in the textbook can also be helpful. Use the handout attached to the initial announcement this week to make sure you wrote the correct Ho and Ha in step 1.
    • Name the descriptive statistics related to the DV and the inferential test used to test the hypothesis you wrote in Step 1 of hypothesis testing.
    • Give the p-value used by the researchers. The p-value the researcher used to test the null hypothesis is often given in this paragraph. It can be called the level of significance or alpha value. If this value is not given, the assume that the p-value or level of significance or alpha value is 0.05
  • Step 3: Check Assumptions of the Chosen Test. This will be covered in future weeks with the content for each inferential test.
  • Step 4: Compute the Test Statistics and Find the p-Value. From the Results section, give the values for the descriptive statistics, test statistic (if given), and the p-value for the null hypothesis you wrote.
  • Step 5: Use the p-Value to Quantify Evidence Against the Null Hypothesis.
    • The p-value rule is: if the p-value is < alpha (0.05), then reject the null hypothesis.
    • If the p-value is > alpha (0.05), then fail to reject the null hypothesis.
    • Use the appropriate rule for the results of the inferential test you identified in Step 2.
    • Given the results of the study, a Type 1 or Type 2 error is possible. Based on statistical testing, only one type of error is possible. Given the results of the study, which type of error is possible given the evidence related to the null hypothesis? What are the most common reasons for this type of error.
• If the effect size is reported, give the value and interpret it. If the effect size is not given or even if it is given, examine the descriptive statistic values for the variable and use your knowledge, critical thinking, and experience with your patients and setting to determine the clinical significance of the result… would you recommend using the experimental treatment because the magnitude of the effect is great enough to justify the cost and effort of implementing it in practice? Give the rationale for your answer.