Tag: Care Plans

  • [Solved] 9-1 Capstone Project

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    Follow rubric Verbatim What to Submit Your comprehensive program proposal should be 12 to 15 pages in length (plus a cover page and references) and written in APA format. Use double spacing, 12-point Times New Roman font, and one-inch margins. – [\ \ rubric1.pdf](https://www.sweetstudy.com/files/r…

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    Assignment Prompt & Instructions

    Follow rubric Verbatim

    What to Submit

    Your comprehensive program proposal should be 12 to 15 pages in length (plus a cover page and references) and written in APA format. Use double spacing, 12-point Times New Roman font, and one-inch margins.

    – [\
    \
    rubric1.pdf](https://www.sweetstudy.com/files/rubric1-pdf-10289611 "rubric1.pdf")

    – a year ago

  • [Solved] Discussion 581 week 3

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    Follow these guidelines when completing each component of the discussion. Contact your course faculty if you have questions. Include the following sections: 1. **Application of Course Knowledge**: Answer all questions/criteria with explanations and detail. – Identify and briefly describe one of the …

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    Assignment Prompt & Instructions

    Follow these guidelines when completing each component of the discussion. Contact your course faculty if you have questions.

    Include the following sections:

    1. **Application of Course Knowledge**: Answer all questions/criteria with explanations and detail.

    – Identify and briefly describe one of the nursing or interprofessional theories presented in the lesson that may be used in advanced nursing practice.
    – Explain the relevance of the theory to your intended practice specialty.
    – Describe a current healthcare issue, societal need, or practice problem in your intended practice specialty.
    – Analyze how the chosen theory could be applied to address the problem.

    – Cite a scholarly source in the initial post.

    1. **Professionalism in Communication**: Communicate with minimal errors in English grammar, spelling, syntax, and punctuation.
    2. **Reference Citation**: Use current APA format to format citations and references and is free of errors.

    please provide AI and similarity report

    – a year ago

  • [Solved] disc1psychotherapy

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    Psychotherapy is often misunderstood or devalued. – Discuss your views of the PMHNP as a psychotherapist – Discuss whether it is feasible to provide psychotherapy at each patient encounter post should be at least 500 words, formatted, and cited in current APA style with support from at least 2 acade…

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    Assignment Prompt & Instructions

    Psychotherapy is often misunderstood or devalued.

    – Discuss your views of the PMHNP as a psychotherapist
    – Discuss whether it is feasible to provide psychotherapy at each patient encounter

    post should be at least 500 words, formatted, and cited in current APA style with support from at least 2 academic sources.

    – a year ago

  • [Solved] NUR 520 Discussion

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    I need assistant with my discussion post please. – a year ago **files (1)** – ## NUR520Discussion.pdf **## NUR520Discussion.pdf** Discussion 1 Chemical Neurotransmission Modern psychopharmacology is largely the story of chemical neurotransmission. One must be fluent in the language and principles of…

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    Assignment Prompt & Instructions

    I need assistant with my discussion post please.

    – a year ago

    **files (1)**

    – ## NUR520Discussion.pdf

    **## NUR520Discussion.pdf**

    Discussion 1

    Chemical Neurotransmission

    Modern psychopharmacology is largely the story of chemical neurotransmission. One
    must be fluent in the language and principles of chemical neurotransmission to:

    • Understand the actions of drugs on the brain.

    • Grasp the impact of diseases upon the central nervous system.

    • Interpret the behavioral consequences of psychiatric medicines.

    After studying Module 1: Lecture Materials & Resources, discuss the following:

    • Choose an FDA-approved medication currently used in psychiatry.

    • Explain the concept of that drug’s half-life.

    • How long would it take for that drug to reach a steady state?

    • How frequently should the medication be dosed based on the half-life?

    • Use Epocrates.com as a reference for this assignment.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in current APA
    style with support from at least 2 academic sources.  Your initial post is worth 8
    points.

    [https://stu.instructure.com/courses/45431/pages/module-1-lecture-materials-and-resources](https://stu.instructure.com/courses/45431/pages/module-1-lecture-materials-and-resources)

    Discussion 2

    Depressive Disorders

    Answer the questions below based on the following case study.

    A 41-year-old man presents to his PCP with feelings of hopelessness, sadness, and
    helplessness. He says that he cries for no reason, and has difficulty sleeping. He
    noticed that the problems began about 6 weeks before, and he did not feel able to
    shrug them off. He has been drinking more alcohol than usual and has stopped going to
    work. When on his own, he admitted that he had thought of driving his car into the
    nearest canal.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe including the name,

    dose, route and frequency of the drug in accordance with the clinical guidelines?
    Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the
    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in the current
    APA style with support from at least 2 academic sources.  Your initial post is
    worth 8 points.

    Discussion 3

    Anxiety & Sleep Wake Disorders

    Answer the questions below based on the following case study.

    A 26-year-old woman presented to the clinic after her cleaning rituals had so exhausted
    her that she had given up and could now enter only two of the five rooms in her home.
    For more than a year she has worried that if her house is not sufficiently clean, her 3-
    year-old son will become ill and could die. Having touched a surface she has to
    disinfect it repeatedly – a procedure performed in a particular way and taking several
    hours. In addition, she repetitively washes her hands and sterilizes all the crockery and
    cutlery before eating. She realizes that she is ‘going over the top’, but she cannot stop
    thinking that items may have germs on them. This leads to disabling anxiety and fear for
    her son’s health, which she can only resolve by cleaning. This helps temporarily, but
    soon the thoughts return again.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe according to the clinical

    guidelines? Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the

    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in the current
    APA style with support from at least 2 academic sources.  Your initial post is
    worth 8 points.

    Discussion 4

    Bipolar Disorders

    Answer the questions below based on the following case study.

    A 20-year-old woman with a past history of MDD is brought to the local emergency
    department (ED) by her family. She appears restless, pacing around the waiting room,
    and her parents say that she has recently been asked to leave her job as a tattoo artist.
    She has not slept for four nights, and her speech is rapid and quickly wanders off the
    point. She had recently purchased a $20,000 car and a $40,000 van to jump-start her
    mobile tattoo business in Naples, Florida. She is very reluctant to remain in the ED
    department because she has far too much to do and considers it a waste of everyone’s
    time. She believes that she is far too important to be held back by minions.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe according to the clinical

    guidelines? Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the

    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in current APA
    style with support from at least 2 academic sources.  Your initial post is worth 8
    points.

    Discussion 5

    Psychotic & Cognitive Disorders

    Answer the questions below based on the following case study.

    TM is a 79-year-old man who was diagnosed with dementia 6 years previously. He lives
    with his 72-year-old wife. He was a chain smoker for 45 years.  She describes a gradual
    deterioration in his condition such that in recent months she has found it increasingly
    difficult to manage him. He has become increasingly hostile and aggressive, though he
    has not actually assaulted her. He has begun to complain about seeing people
    wandering around the house, and that frightens him. On two occasions he has left the
    house and been found wandering along the road. She has noticed that his condition
    fluctuates – sometimes he is very aggressive and confused, while at other times he is
    more calm and lucid.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe according to the clinical

    guidelines? Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the

    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in the current
    APA style with support from at least 2 academic sources.  Your initial post is
    worth 8 points.

    Discussion 6

    Attention & Substance Related Disorders

    Answer the questions below based on the following case study.

    An 8-year-old boy is repeatedly in trouble at school. He has been threatened with
    suspension after he was verbally and physically aggressive to his teacher. The school
    has suggested that he has a problem with his concentration and advised his parents to
    seek help.  The school also referred him to the school child psychologist. He keeps
    wriggling in his seat. His mother says his concentration is fine when he is playing on his
    computer. What worries her is that he does not seem to think before he does things and
    will run out across the road without looking.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe according to the clinical

    guidelines? Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the

    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in current APA
    style with support from at least 2 academic sources.  Your initial post is worth 8
    points.

    •

    **## NUR520Discussion.pdf**

    Discussion 1

    Chemical Neurotransmission

    Modern psychopharmacology is largely the story of chemical neurotransmission. One
    must be fluent in the language and principles of chemical neurotransmission to:

    • Understand the actions of drugs on the brain.

    • Grasp the impact of diseases upon the central nervous system.

    • Interpret the behavioral consequences of psychiatric medicines.

    After studying Module 1: Lecture Materials & Resources, discuss the following:

    • Choose an FDA-approved medication currently used in psychiatry.

    • Explain the concept of that drug’s half-life.

    • How long would it take for that drug to reach a steady state?

    • How frequently should the medication be dosed based on the half-life?

    • Use Epocrates.com as a reference for this assignment.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in current APA
    style with support from at least 2 academic sources.  Your initial post is worth 8
    points.

    [https://stu.instructure.com/courses/45431/pages/module-1-lecture-materials-and-resources](https://stu.instructure.com/courses/45431/pages/module-1-lecture-materials-and-resources)

    Discussion 2

    Depressive Disorders

    Answer the questions below based on the following case study.

    A 41-year-old man presents to his PCP with feelings of hopelessness, sadness, and
    helplessness. He says that he cries for no reason, and has difficulty sleeping. He
    noticed that the problems began about 6 weeks before, and he did not feel able to
    shrug them off. He has been drinking more alcohol than usual and has stopped going to
    work. When on his own, he admitted that he had thought of driving his car into the
    nearest canal.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe including the name,

    dose, route and frequency of the drug in accordance with the clinical guidelines?
    Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the
    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in the current
    APA style with support from at least 2 academic sources.  Your initial post is
    worth 8 points.

    Discussion 3

    Anxiety & Sleep Wake Disorders

    Answer the questions below based on the following case study.

    A 26-year-old woman presented to the clinic after her cleaning rituals had so exhausted
    her that she had given up and could now enter only two of the five rooms in her home.
    For more than a year she has worried that if her house is not sufficiently clean, her 3-
    year-old son will become ill and could die. Having touched a surface she has to
    disinfect it repeatedly – a procedure performed in a particular way and taking several
    hours. In addition, she repetitively washes her hands and sterilizes all the crockery and
    cutlery before eating. She realizes that she is ‘going over the top’, but she cannot stop
    thinking that items may have germs on them. This leads to disabling anxiety and fear for
    her son’s health, which she can only resolve by cleaning. This helps temporarily, but
    soon the thoughts return again.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe according to the clinical

    guidelines? Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the

    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in the current
    APA style with support from at least 2 academic sources.  Your initial post is
    worth 8 points.

    Discussion 4

    Bipolar Disorders

    Answer the questions below based on the following case study.

    A 20-year-old woman with a past history of MDD is brought to the local emergency
    department (ED) by her family. She appears restless, pacing around the waiting room,
    and her parents say that she has recently been asked to leave her job as a tattoo artist.
    She has not slept for four nights, and her speech is rapid and quickly wanders off the
    point. She had recently purchased a $20,000 car and a $40,000 van to jump-start her
    mobile tattoo business in Naples, Florida. She is very reluctant to remain in the ED
    department because she has far too much to do and considers it a waste of everyone’s
    time. She believes that she is far too important to be held back by minions.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe according to the clinical

    guidelines? Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the

    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in current APA
    style with support from at least 2 academic sources.  Your initial post is worth 8
    points.

    Discussion 5

    Psychotic & Cognitive Disorders

    Answer the questions below based on the following case study.

    TM is a 79-year-old man who was diagnosed with dementia 6 years previously. He lives
    with his 72-year-old wife. He was a chain smoker for 45 years.  She describes a gradual
    deterioration in his condition such that in recent months she has found it increasingly
    difficult to manage him. He has become increasingly hostile and aggressive, though he
    has not actually assaulted her. He has begun to complain about seeing people
    wandering around the house, and that frightens him. On two occasions he has left the
    house and been found wandering along the road. She has noticed that his condition
    fluctuates – sometimes he is very aggressive and confused, while at other times he is
    more calm and lucid.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe according to the clinical

    guidelines? Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the

    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in the current
    APA style with support from at least 2 academic sources.  Your initial post is
    worth 8 points.

    Discussion 6

    Attention & Substance Related Disorders

    Answer the questions below based on the following case study.

    An 8-year-old boy is repeatedly in trouble at school. He has been threatened with
    suspension after he was verbally and physically aggressive to his teacher. The school
    has suggested that he has a problem with his concentration and advised his parents to
    seek help.  The school also referred him to the school child psychologist. He keeps
    wriggling in his seat. His mother says his concentration is fine when he is playing on his
    computer. What worries her is that he does not seem to think before he does things and
    will run out across the road without looking.

    1. Summarize the clinical case.

    2. What is the DSM 5-TR diagnosis based on the information provided in the case?

    3. Which pharmacological treatment would you prescribe according to the clinical

    guidelines? Include the rationale for this treatment.

    4. Which non-pharmacological treatment would you prescribe according to the

    clinical guidelines? Include the rationale for this treatment excluding a
    psychotherapeutic modality.

    5. Include an assessment of the treatment’s appropriateness, cost, effectiveness,
    safety, and potential for patient adherence to the chosen medication. Use a local
    pharmacy to research the cost of the medication and provide the most cost-
    effective choice for the patient. Use great detail when answering questions 3-5.

    Submission Instructions:

    • Your initial post should be at least 500 words, formatted and cited in current APA
    style with support from at least 2 academic sources.  Your initial post is worth 8
    points.

    •

  • [Solved] networking, academic, professional

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    In-depth study guidance and analytical solution covering networking, academic, professional.

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    Assignment Prompt & Instructions

    Full assignment prompt and step-by-step guidance are included in the downloadable solution file.

  • [Solved] Mit week 2 soap

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    – a year ago **files (1)** – ## SOAPNoteTemplate-Final13.docx **## SOAPNoteTemplate-Final13.docx** | | | | — | — | | **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: ______…

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    – a year ago

    **files (1)**

    – ## SOAPNoteTemplate-Final13.docx

    **## SOAPNoteTemplate-Final13.docx**

    | | |
    | — | — |
    | **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**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 data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
    | PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
    | ALLERGIES | State the offending medication/food and the reactions. |
    | MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
    | SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
    | FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
    | HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
    | ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
    | | Head | |
    | | Eyes | |
    | | Ears, Nose, Mouth, Throat | |
    | | Neck | |
    | | Cardiovascular/Peripheral Vascular | |
    | | Respiratory | |
    | | Breast | |
    | | Gastrointestinal | |
    | | Genitourinary | |
    | | Musculoskeletal | |
    | | Integumentary | |
    | | Neurological | |
    | | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
    | | Endocrine | |
    | | Hematologic/Lymphatic | |
    | | Allergic/Immunologic | |
    | | Other | |

    | | | | | |
    | — | — | — | — | — |
    | O: OBJECTIVE DATA |
    | VITALS: | HR: | RR: | BP: | Temp: |
    | | SpO2%: | Ht: | Wt: | BMI: |
    | | Age: | LMP: | PAIN: | |
    | PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | |
    | | Head | |
    | | Eyes | |
    | | ENT, Mouth | |
    | | Neck | |
    | | Cardiovascular/Peripheral Vascular | |
    | | Respiratory | |
    | | Breast | |
    | | Gastrointestinal | |
    | | Genitourinary Male |
    | | · External Exam | |
    | | · Internal Exam | |
    | | Genitourinary Female |
    | | · External Exam | |
    | | · Internal Exam | |
    | | Musculoskeletal | |
    | | Integumentary | |
    | | Neurological | |
    | | Psychiatric | |
    | | Endocrine | |
    | | Hematologic/Lymphatic | |
    | | Allergic/Immunologic | |
    | | Other | |

    | | | |
    | — | — | — |
    | A: ASSESSMENT AND DIAGNOSIS |
    | | DIAGNOSIS | ICD-10 CODES |
    | PRIORITIZE DIAGNOSIS | 1. | |
    | | 2. | |
    | | 3. | |

    | | | | |
    | — | — | — | — |
    | VISIT CODES | | CPT BILLING CODES | |
    | DIAGNOSTICS | | POC TESTING | |
    | | | TESTS REVIEWED | |

    | | | |
    | — | — | — |
    | P: PLAN |
    | ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
    | | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
    | | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
    | PREVENTITIVE <br> <br>(Used for comprehensive exams) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
    | FOLLOW UP | | |

    **## SOAPNoteTemplate-Final13.docx**

    | | |
    | — | — |
    | **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**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 data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
    | PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
    | ALLERGIES | State the offending medication/food and the reactions. |
    | MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
    | SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
    | FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
    | HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
    | ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
    | | Head | |
    | | Eyes | |
    | | Ears, Nose, Mouth, Throat | |
    | | Neck | |
    | | Cardiovascular/Peripheral Vascular | |
    | | Respiratory | |
    | | Breast | |
    | | Gastrointestinal | |
    | | Genitourinary | |
    | | Musculoskeletal | |
    | | Integumentary | |
    | | Neurological | |
    | | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
    | | Endocrine | |
    | | Hematologic/Lymphatic | |
    | | Allergic/Immunologic | |
    | | Other | |

    | | | | | |
    | — | — | — | — | — |
    | O: OBJECTIVE DATA |
    | VITALS: | HR: | RR: | BP: | Temp: |
    | | SpO2%: | Ht: | Wt: | BMI: |
    | | Age: | LMP: | PAIN: | |
    | PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | |
    | | Head | |
    | | Eyes | |
    | | ENT, Mouth | |
    | | Neck | |
    | | Cardiovascular/Peripheral Vascular | |
    | | Respiratory | |
    | | Breast | |
    | | Gastrointestinal | |
    | | Genitourinary Male |
    | | · External Exam | |
    | | · Internal Exam | |
    | | Genitourinary Female |
    | | · External Exam | |
    | | · Internal Exam | |
    | | Musculoskeletal | |
    | | Integumentary | |
    | | Neurological | |
    | | Psychiatric | |
    | | Endocrine | |
    | | Hematologic/Lymphatic | |
    | | Allergic/Immunologic | |
    | | Other | |

    | | | |
    | — | — | — |
    | A: ASSESSMENT AND DIAGNOSIS |
    | | DIAGNOSIS | ICD-10 CODES |
    | PRIORITIZE DIAGNOSIS | 1. | |
    | | 2. | |
    | | 3. | |

    | | | | |
    | — | — | — | — |
    | VISIT CODES | | CPT BILLING CODES | |
    | DIAGNOSTICS | | POC TESTING | |
    | | | TESTS REVIEWED | |

    | | | |
    | — | — | — |
    | P: PLAN |
    | ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
    | | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
    | | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
    | PREVENTITIVE <br> <br>(Used for comprehensive exams) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
    | FOLLOW UP | | |

  • [Solved] Mit week 2 medications

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    – a year ago

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  • [Solved] HCP Week 2 Discussion

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    Public Health and the Implementation of Media for Advancement Identify a specific public health issue that you believe needs to be highlighted more in health policy and based on your textbook readings discuss how social media can be used as a health promotion tool to improve public awareness on the …

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    Public Health and the Implementation of Media for Advancement

    Identify a specific public health issue that you believe needs to be highlighted more in health policy and based on your textbook readings discuss how social media can be used as a health promotion tool to improve public awareness on the selected healthcare issue.

    Please be sure to adhere to the following when posting your weekly discussions:

    1. A minimum of 2 paragraphs is required for all posts

    2. All discussion posts must be minimum 250 words, references must be cited in APA format 7th Edition, and must include minimum of 2 different scholarly resources published within the past 5 years.

    – a year ago

  • [Solved] Examine and explain the significance of the Declaration of Independence to the development of the American Revolution.

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    In-depth study guidance and analytical solution covering Examine and explain the significance of the Declaration of Independence to the development of the American Revolution..

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  • [Solved] week 4 collaboration

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    582 collaboration Reflect upon your current or previous workplace organization, and consider the organizational mission, vision, and values, as well as the organizational culture, and leadership practices then discuss the following: (work place organizaton is RWJBarnabas Health) **Include the follow…

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    582 collaboration

    Reflect upon your current or previous workplace organization, and consider the organizational mission, vision, and values, as well as the organizational culture, and leadership practices then discuss the following:  (work place organizaton is RWJBarnabas Health)

    **Include the following sections**:

    1. **Application of Course Knowledge**:      Answer all questions/criteria with explanations and detail.

    1. State  the name of the organization and share their mission, vision, and values  (note: the organization you choose must have all three elements).       Describe the mission, vision, and values of the organization. To what       extent are the behaviors of leaders in the organization congruent with the mission, vision, and values?
    2. To what extent are the mission, vision, and values congruent with nursing       core values?
    3. How were the mission, vision, and values similar to and different from your       personal philosophy of nursing?

    2. **Professionalism in Communication**: Communicate with minimal errors in English grammar, spelling, syntax, and punctuation.

    please add AI and similarity report

    – a year ago