Soap note Study guides, Class notes & Summaries

NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation/NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation/NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation/NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation

what is the primary function of a medical scribe? - create the medical note what is the preferred format for the creation of the medical note? - subjective, objective, assessment, plan (soap) "present time" pt details are summarized by using what format - OPQRST all current procedural terminology (CPT) codes must be justified by what appropiate coding mechanisms - international classification of disease (ICD) what patient history is outlined in the PMHx - medical history what scribing i...

WOMEN’S HEALTH MINI SOAP NOTES A 25-year-old woman comes to the clinic complaining of increased vaginal discharge, milky gray in color with a "fishy" odor that both she and her husband have noticed. A wet smear is performed and the presence of "clue cells" confirmed. Which type of infection does the nurse suspect? 1 Candidiasis 2 Trichomoniasis 3 Bacterial vaginosis 4 Group B Streptococcus - ANS -Bacterial vaginosis Signs of bacterial vaginosis include a milky gray vaginal...

HEENT SOAP NOTE with complete solution HEENT SOAP NOTE Jewel Concepcion United States University MSN 572 Advanced Physical Assessment Dr. Sherian Wilmot-Carter March 27, 2023

:Section 1 Patient Initials: J.A. Age: 58 y/o Gender: Male Race: Caucasian ”.Chief complaint: “I’ve been having some chest discomfort · :HPI · OLDCARTS o J.A. is a 58 y/o healthy man presenting to care provider with a o complaint of recent episodes of burning chest discomfort X 4 days. Rating substernal pain 4-5/10 at its worst, radiating into his neck. Current pain of 1-2/10. Borderline-obese. Well controlled HTN, on Lopressor, and borderline lipid abnormality. Recent stres...

Name: Carolyn Cross Date: 3/18/2017 Time: 21:00am elmdtn Patient Encounter # 4140505 Age: 41 years Sex: Female CC: This 41-year-old male presents a chronic cough. She said, “My throat is painful, I cough frequently. There seems to be nothing to relieve it when I started to cough.” HPI: Carolyn Cross confirms that coughing started almost four weeks ago after failing to wear a sweater, during one cold morning when attending a job. Carolyn Cross added that chronic coughing started one wee...

NURS 3150 soap note Fall 2023 Subjective Data A. Chief Complain (CC): “I need a primary care doctor and I also have an injury to my toe” B. History of Present Illness (HPI): C. Last Menstrual Period– Not applicable. D. Allergies: NKDA E. Past Medical History: Hypertension and diabetes II F. Family History: Father – Diabetes and Glaucoma Mother – Hypertension G. Surgery History- None H. Social History- Denies drug use, alcohol and tobacco use, Erickson developmental stage...

NRNP 6665 Assignment 2 Focused SOAP Note and Patient Case Presentation, NRNP 6665 PMHNP Care Across the Lifespan I, Walden University.

NRNP 6552 Wk3Assgn2,Case study (Walden university) Case Study 2 Case Study: STI Investigation Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full- time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / EtOH ...

Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Rating: Allergies (and reaction) 170 cm 88 kg 139/ 87 82 bpm 16 98.9 99% Medication: Penicillin- rash/ hives Food: no known allergies Environment: Cat dander and dust- cat dander and dust- rhinorrhea, pruritic and periorbital edema, wheezing History of Present Illness (HPI) Chief Complaint (CC) “Headache & neck symptoms” CC is a BRIEF statement identifying why the patient is here - in the patient’s own words...