Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

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. Use LOCATES Mnemonic to complete your HPI. 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. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of
last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
General:
Head:
EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History.
Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A

.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P.
  

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

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

Trends in Informatics

Discussion

Purpose

This week's graded discussion topic relates to the following Course Outcomes (COs).

Preparing the Discussion

· Discussions are designed to promote dialogue between faculty and students, and students and their peers. In discussions students:

· Demonstrate understanding of concepts for the week

· Integrate outside scholarly sources when required

· Engage in meaningful dialogue with classmates and/or instructor

· Express opinions clearly and logically, in a professional manner

· Use the rubric on this page as you compose your answers.

· Best Practices include:

· Participation early in the week is encouraged to stimulate meaningful discussion among classmates and instructor.

· Enter the discussion often during the week to read and learn from posts.

· Select different classmates for your reply each week.

Discussion Question

This is the week to really see where technology and healthcare are connecting. Select ONE of the following trends and discuss your understanding of this trend in healthcare and its potential impact on your practice as a nurse. What are the legal, privacy, and ethical considerations of this trend? (Everyone attempt to choose a different topic so that we will learn about the many advancements in technology).

· Nanotechnology

· Consumer health informatics (CHI)

· Social media healthcare applications

· Health-focused wearable technology

· eHealth

· Artificial Intelligence

· Simulation

· Computerized provider order entry (CPOE)

· Bar Code Medication Administration (BCMA)

· Creative measures in healthcare for use with 3D printers

· Smart Pumps

· Smart Rooms

· Robotics in healthcare

· Mobile technology in outpatient care

· Web-based tools and software technology

· Risk Management tools

· Chatbots or Bots in healthcare

· Telenursing

· Telemedicine

· Telepharmacy

· Telerehabilitation

· Teleconsultation

· Telehospice

· Technology advancement from your clinical practice

· Palm Vein Technology

· Microchip use in healthcare

· Optical head-mounted computer glasses (Google Glass)

· Smart hospital beds

· EBOOK to use for one citation:

· https://bookshelf.vitalsource.com/reader/books/9781323903148/epubcfi/6/492%5B%3Bvnd.vst.idref%3DP7001015544000000000000000002CB2%5D!/4/2%5BP7001015544000000000000000002CB2%5D/2/2%5BP7001015544000000000000000002CB3%5D/7:6%5B%20In%2Cter%5D

· email:
[email protected]

· Pwd: Leroyismyhero1#

·

let me know if you cannot have access to the ebook

·
Prof needs one citation from the ebook and one external citation

· At least 2 citations

Resources

• McCance, K. L. & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.
  • Chapter 15: Structure and Function of the Neurologic System
  • Chapter 16: Pain, Temperature Regulation, Sleep, and Sensory Function (stop at Sleep); Summary Review
  • Chapter 17: Alterations in Cognitive Systems, Cerebral Hemodynamics, and Motor Function (start at Acute confusional states and delirium) (stop at Alterations in neuromotor functions); (Parkinson’s Disease); Summary Review
  • Chapter 18: Disorders of the Central and Peripheral Nervous Systems and the Neuromuscular Junction (stop at Degenerative disorders of the spine); (start at Cerebrovascular disorders) (stop at Tumors of the central nervous system); Summary Review
  • Chapter 44: Structure and Function of the Musculoskeletal System (stop at Components of muscle function); Summary Review
  • Chapter 45: Alterations of Musculoskeletal Function (stop at Bone tumors); (start at Disorders of joints); Summary Review
  • Chapter 47: Structure, Function, and Disorders of the Integument (section on Lyme Disease)
• Chin, L. S. (2018). Spinal cord injuriesLinks to an external site.. Retrieved from https://emedicine.medscape.com/article/793582-overview#a4

 

In your Case Study Analysis related to the scenario provided, explain the following:

• Both the neurological and musculoskeletal pathophysiologic processes that would account for the patient presenting these symptoms.
• Any racial/ethnic variables that may impact physiological functioning.
• How these processes interact to affect the patient.

Chamberlain

NR599-11532

Week 8

Midweek Comprehension Questions

Discussion

Purpose

NI knowledge, skills, and competencies are so pervasive in the modern technology-rich healthcare environment it is difficult to imagine one without the other. This course provided foundational and introductory knowledge regarding informatics with an emphasis on developing an understanding of concepts of nursing informatics (NI) and becoming knowledgeable about the application of informatics in advanced practice. Reflect upon one NI competency relevant to APNs which you learned in this course. Provide a brief summary (100 words or less)