Our Services

Get 15% Discount on your First Order

Problem-focused SOAP Note Format Demographic Data · Age, and gender (must be HIPAA compliant)

May 20, 2025

Problem-focused SOAP Note Format

Demographic Data

· Age, and gender (must be HIPAA compliant)

Subjective

· Chief Complaint (CC): A short statement about why they are there

· History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment

· Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance

· Family Hx: any history of CA, DM, HTN, MI, CVA?

· Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.

· Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

· Vital Signs

· Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

Assessment (the diagnosis)

· At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each

· Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

Plan

· Dx Plan (lab, x-ray)

· Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)

· Pt. Education, including specific medication teaching points

· Referral/Follow-up

· Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

Reference

· Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

>Nursing homework help

Share This Post

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

Related Questions

Negotiating the Nurse Practitioner Employment Contract If you could work at the practice of your dreams, what would that look like?

Negotiating the Nurse Practitioner Employment Contract If you could work at the practice of your dreams, what would that look like? How would you negotiate that dream job contract? Graduating from nurse practitioner school is an exciting time of accomplishment. However, it’s also time to turn dreams into reality and

image1.png image2.png image3.png image4.png

image1.png image2.png image3.png image4.png image5.png

Schizophrenia and Other Psychotic Disorders; Medication-Induced Movement Disorders

For this assignment, answer the following questions: · What are the Pros and Cons to telehealth? · How will you approach and perform a telehealth a

For this assignment, answer the following questions: · What are the Pros and Cons to telehealth? · How will you approach and perform a telehealth assessment? · What are the limits to telehealth? · What is the difference between the provider’s need for a successful telehealth visit versus the Patient’s

The purpose of this assignment is to complete a review of a screening tool utilized by nurse practitioners in maintaining individual, family, or

The purpose of this assignment is to complete a review of a screening tool utilized by nurse practitioners in maintaining individual, family, or community health. PHQ-9 (Patient Health Questionnaire-9) Your presentation should: 1. Identify and select a screening tool 2. Research of ethical, economical and legal issues relative to the practice in relation to

· An effective health assessment incorporates not only physiological parameters; please suggest other parameters that should be considered and

· An effective health assessment incorporates not only physiological parameters; please suggest other parameters that should be considered and included on health assessments to reach maximal health potential on individuals. · Name the different family developmental stages and give examples of each one. · Describe family structure and function and

ANSWER QUESTIONS: 1. What other subjective data would you obtain? 2. What other objective findings would you look for? 3. What diagnostic exams do

ANSWER QUESTIONS: 1. What other subjective data would you obtain? 2. What other objective findings would you look for? 3. What diagnostic exams do you want to order? 4. Name 3 differential diagnoses based on this patient presenting symptoms? 5. Give rationales for each of your differential diagnoses. INSTRUCTIONS: ·

Develop a disaster recovery plan to reduce health disparities and improve access to community services after a disaster. Then develop a brochure,

Develop a disaster recovery plan to reduce health disparities and improve access to community services after a disaster. Then develop a brochure, storyboard, or poster communicating the plan for the local system, city officials, and the disaster relief team. Nurses perform a variety of roles and their responsibilities as healthcare

Please attached. Week 4 Discussion Post Abuse Using the ICHS online library, find an evidence-based article on elder abuse or child abuse. Write a

Please attached. Week 4 Discussion Post Abuse Using the ICHS online library, find an evidence-based article on elder abuse or child abuse. Write a summary of the article and whether you agree with the article related to the diagnosis of abuse. Why do you agree or disagree? Article: What

Ll A. Write a paper (suggested length of 4–7 pages) reflecting on your experiences during the Interprofessional Leadership and Communication course

Ll A. Write a paper (suggested length of 4–7 pages) reflecting on your experiences during the Interprofessional Leadership and Communication course, including the following formatting requirements: • double-spaced text with one-inch margins • a heading at the top of page one of the paper with your name, the course name,

Assignment including Influential Nursing Professional and Personal Strengths and Leadership Traits

CONTROVERSY ASSOCITED WITH DISSOCIATIVE DISORDERS · PREPARE: Review this week’s Learning Resources on

CONTROVERSY ASSOCITED WITH DISSOCIATIVE DISORDERS · PREPARE: Review this week’s Learning Resources on dissociative disorders. · Use the Walden Library to investigate the controversy regarding dissociative disorders. Locate at least three scholarly articles that you can use to support your Assignment. · · · ASSIGNMENT :2-3pages · · Explain the

see attached SMART Goal Goal 1 Specific: Learning decision-making skills from my

see attached SMART Goal Goal 1 Specific: Learning decision-making skills from my preceptor to broaden my expertise and present as a great leader. Measurable: Improvement in decision-making skills Attainable: Attend meetings, collect data, ask questions Results-focused: Enhance ability to make accurate and effective decision for the resident and the company.

Analyze and evaluate a middle range theory. You will select a middle range theory and identify application of nursing theories into clinical practice.

Analyze and evaluate a middle range theory. You will select a middle range theory and identify application of nursing theories into clinical practice. Content Requirements: Components of the theory Discuss the major concepts of the theory Philosophical basis or worldview change, advancing health Structural aspects of the theory Discuss the

Which learning theories and principles do you think are most useful to the advanced practice nurse (APN) in providing high quality health care to

Which learning theories and principles do you think are most useful to the advanced practice nurse (APN) in providing high quality health care to clients, and why?

SCOREMORE IS ONE STOP SOLUTION FOR ALL YOUR ASSIGNMENTS, PROJECTS AND EXAMS CONTACT US NOW For further information:

SCOREMORE IS ONE STOP SOLUTION FOR ALL YOUR ASSIGNMENTS, PROJECTS AND EXAMS CONTACT US NOW For further information: +91-9953193725 +1 518-333-5888 Instagram: scoremore.info Facebook: Telegram: Website: scoremore.co.in Open this link to join my WhatsApp Community: #students #grades #university #InternationalStudents #AcademicExcellence #assignmenthelp #studentsupport #homeworkassistance #Lastminutehelp ScoremorePro image1.png image2.png

Identify a current research problem related to advanced nursing practice that is of interest to you. Include WHY this is a problem. (Limit response to

Identify a current research problem related to advanced nursing practice that is of interest to you. Include WHY this is a problem. (Limit response to no more than 3 sentences). Develop a research question to provide information about the research problem.