Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.  

Review the rubric for more information on how your assignment will be graded. 

Demographic Data 

· Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant. 

Subjective 

· Chief Complaint (CC) 

· History of Present Illness (HPI) (symptoms) in paragraph format 

· Past Medical History (PMH): Current problem-focused and document pertinent information only. 

· Current Medications:  

· Medication Allergies: 

· Social History: For current problem-focused and document only pertinent information only.  

· Family History: For current problem-focused and document only pertinent information only.  

· Review of Systems (ROS) as appropriate:  

Objective 

· Vital signs 

· Mental Status Exam 

· Physical findings listed by body systems, not paragraph form. 

· Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal) 

Assessment (Diagnosis/ICD10 Code) 

· Include all diagnoses that apply to this visit. 

· Include one differential diagnosis. 

Plan 

· Dx Plan (lab, x-ray) 

· Tx Plan: (meds) 

· Pt. Education, including specific medication teaching points.     

· Safety Plan        

· Referral/Follow-up 

*Based on population focus, some additional details may be required by faculty Top of Form 

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Week 6 Assignment: Nursing Informatics Project Proposal Your Name Program Name or Degree Name, Walden University Nursing 8210: Transforming

Week 6 Assignment: Nursing Informatics Project Proposal Your Name Program Name or Degree Name, Walden University Nursing 8210: Transforming Nursing Instructor Name Month XX, 202X Introduction Content: Brief introduction to the project requirements and objectives Formatting Notes: Choose formatting that presents your information in the most logical way. You may

Week 6 Assignment: Nursing Informatics Project Proposal Your Name Program Name or Degree Name, Walden University Nursing 8210: Transforming

Week 6 Assignment: Nursing Informatics Project Proposal Your Name Program Name or Degree Name, Walden University Nursing 8210: Transforming Nursing Instructor Name Month XX, 202X Introduction Content: Brief introduction to the project requirements and objectives Formatting Notes: Choose formatting that presents your information in the most logical way. You may

Help responding to collegues Please respond to the following colleaguesAS Angela

Help responding to collegues  Please respond to the following colleagues AS Angela Stapleton-Burley Jun 25 10:56pm Manage Discussion by Angela Stapleton-Burley Reply from Angela Stapleton-Burley   Hi Everoyne, One significant benefit of incorporating big data into clinical systems is the enhancement of predictive analytics, which allows providers to proactively identify