Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details

Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.

· Upload a copy of your completed SOAP note.

· Upload a copy of the evaluation & management score sheet.

Case Study: A 3-year-old girl is brought to your office by her mother because she has a fever and complains that her right ear hurts. She has no significant medical history. The child is not pleased to be in the PCP’s office and has been crying. Her mother explains that she developed a “cold” about 3 days ago with sniffles. Her temperature is 37.8°C (100°F).  Physical exam was completed with some difficulty because of the child’s irritability.    The only abnormalities are slight redness of the throat, a nose full of thick green mucus, and injected tympanic membranes. She denies nausea, vomiting, diarrhea, headache, or change in urine output. 

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

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

Related Questions

Module 1 Discussion  Nursing & Health-Care-PolicyAnalyze the history,

Module 1 Discussion   Nursing & Health-Care-Policy Analyze the history, structure, and process of health-care-policy and politics in nursing and the health care delivery systems in the United States. Submission Instructions: · Your initial post must be at least 500 words, formatted, and cited in current APA style with support

Week 3 Discussion Part ITable 1Red EyePlease complete the differential

Week 3 Discussion Part I Table 1 Red Eye Please complete the differential diagnosis table for cc: red eye Clinical Findings Diagnosis Treatment/Management Ophthalmia neonatorum Bacterial conjunctivitis Viral conjunctivitis Allergic conjunctivitis Corneal abrasion, foreign body Periorbital Cellulitis Blepharitis Hordeolum (Stye) Chalazion Table 2 Abnormal Ophthalmologic Finings Complete the table Strabismus

See commentsSOAP Note _______ NU___:_________ Herzing University

See comments SOAP Note _______ NU___:_________ Herzing University Name:_________________________ Typhon Encounter #: _____________________ Comprehensive:____Focused:____ S: SUBJECTIVE DATA CC: What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. HPI: Use the “OLDCART” approach for collecting