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  • [Solved] nurs 514 CL soap 3

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    – 2 years ago **files (3)** – ## nurs514CLsoap3.docx – ## SOAPNoteTemplate5.docx – ## SoapNoterubric.docx **## nurs514CLsoap3.docx** · Patient is a 57 year female. · Patient comes in because she has noticed a strong foul smell in her urine. · Has no pain. · No known allergies to meds or anything · N…

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    Assignment Prompt & Instructions

    – 2 years ago

    **files (3)**

    – ## nurs514CLsoap3.docx

    – ## SOAPNoteTemplate5.docx

    – ## SoapNoterubric.docx

    **## nurs514CLsoap3.docx**

    · Patient is a 57 year female.

    · Patient comes in because she has noticed a strong foul smell in her urine.

    · Has no pain.

    · No known allergies to meds or anything

    · No surgeries

    · Only 2 natural labors

    · Doesn’t take an medications, just vitamins

    **_SOAP Note 3_**

    A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

    **Instructions:**

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

    For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

    | | |
    | — | — |
    | **S** = | Subjective data: Patient’s Chief Complaint (CC). |
    | **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
    | **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
    | **P** = | Plan: Treatment, diagnostic testing, and follow up |

    [Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/43383/files/3176310?wrap=1) [Download Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/43383/files/3176310/download?download_frd=1)

    **Submission Instructions:**

    · Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.

    · You must use the template provided. Turnitin will recognize the template and not score against it.

    · Your submission will be reviewed for plagiarism through Turnitin.

    ![null](https://www.sweetstudy.com/questions/nurs-514-cl-soap-3)

    ## image1.png

    **## SOAPNoteTemplate5.docx**

    | | |
    | — | — |
    | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
    | _Demographics_ | |
    | _Chief Complaint (Reason for seeking health care)_ | |
    | _History of Present Illness (HPI)_ | |
    | _Allergies_ | |
    | _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
    | _Vital Signs_ | |
    | _Labs_ | |
    | _Medications_ | |
    | _Past Medical History_ | |
    | _Past Surgical History_ | |
    | _Family History_ | |
    | _Social History_ | |
    | _Health Maintenance/ Screenings_ | |
    | _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
    | _Diagnosis_ | |
    | _Differential Diagnosis_ | |
    | _ICD 10 Coding_ | |
    | _Pharmacologic treatment plan_ | |
    | _Diagnostic/Lab Testing_ | |
    | _Education_ | |
    | _Anticipatory Guidance_ | |
    | _Follow up plan_ | |
    | _Prescription_ | See Below (scroll down) |
    | _References_ | |
    | _Grammar_ | |

    | |
    | — |
    | EA#: 101010101 STU Clinic LIC# 10000000 |
    | Tel: (000) 555-1234 FAX: (000) 555-12222 |
    | Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

    Signature (with appropriate credentials):_____________________________________

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

    **## SoapNoterubric.docx**

    | | |
    | — | — |
    | Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
    | Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
    | History of the Present Illness (HPI) | **5 to >3 pts**<br>**Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)** |
    | Allergies | **2 to >1.5 pts**<br>**Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)** |
    | Review of Systems (ROS) | **2 to >1.5 pts**<br>**Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.** |
    | Labs | **4 to >2 pts**<br>**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)** |
    | Past Medical History | **3 to >2 pts**<br>**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current** |
    | Past Surgical History | **3 to >2 pts**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |

    | | |
    | — | — |
    | Family History | **3 to >2 pts**<br>**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.** |
    | Social History | **3 to >2 pts**<br>**Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation** |
    | Health Maintenance / Screenings | **3 to >2 pts**<br>**Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests** |
    | Physical Examination | **15 to >8 pts**<br>**Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint** |
    | Diagnosis | **5 to >3 pts**<br>**Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)** |
    | Differential Diagnosis | **5 to >3 pts**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
    | Pharmacologic treatment plan | **5 to >3 pts**<br>**Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.** |

    | | |
    | — | — |
    | Diagnostic / Lab Testing | **3 to >2 pts**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
    | Education | **3 to >2 pts**<br>**Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives** |
    | Anticipatory Guidance | **3 to >2 pts**<br>**Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))** |
    | Follow Up Plan | **2 to >1 pts**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
    | Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |

    | | |
    | — | — |
    | Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.** |

    **## SoapNoterubric.docx**

    | | |
    | — | — |
    | Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
    | Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
    | History of the Present Illness (HPI) | **5 to >3 pts**<br>**Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)** |
    | Allergies | **2 to >1.5 pts**<br>**Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)** |
    | Review of Systems (ROS) | **2 to >1.5 pts**<br>**Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.** |
    | Labs | **4 to >2 pts**<br>**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)** |
    | Past Medical History | **3 to >2 pts**<br>**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current** |
    | Past Surgical History | **3 to >2 pts**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |

    | | |
    | — | — |
    | Family History | **3 to >2 pts**<br>**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.** |
    | Social History | **3 to >2 pts**<br>**Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation** |
    | Health Maintenance / Screenings | **3 to >2 pts**<br>**Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests** |
    | Physical Examination | **15 to >8 pts**<br>**Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint** |
    | Diagnosis | **5 to >3 pts**<br>**Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)** |
    | Differential Diagnosis | **5 to >3 pts**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
    | Pharmacologic treatment plan | **5 to >3 pts**<br>**Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.** |

    | | |
    | — | — |
    | Diagnostic / Lab Testing | **3 to >2 pts**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
    | Education | **3 to >2 pts**<br>**Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives** |
    | Anticipatory Guidance | **3 to >2 pts**<br>**Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))** |
    | Follow Up Plan | **2 to >1 pts**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
    | Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |

    | | |
    | — | — |
    | Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.** |

    **## nurs514CLsoap3.docx**

    · Patient is a 57 year female.

    · Patient comes in because she has noticed a strong foul smell in her urine.

    · Has no pain.

    · No known allergies to meds or anything

    · No surgeries

    · Only 2 natural labors

    · Doesn’t take an medications, just vitamins

    **_SOAP Note 3_**

    A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

    **Instructions:**

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

    For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

    | | |
    | — | — |
    | **S** = | Subjective data: Patient’s Chief Complaint (CC). |
    | **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
    | **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
    | **P** = | Plan: Treatment, diagnostic testing, and follow up |

    [Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/43383/files/3176310?wrap=1) [Download Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/43383/files/3176310/download?download_frd=1)

    **Submission Instructions:**

    · Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.

    · You must use the template provided. Turnitin will recognize the template and not score against it.

    · Your submission will be reviewed for plagiarism through Turnitin.

    ![null](https://www.sweetstudy.com/questions/nurs-514-cl-soap-3)

    ## image1.png

    **## SOAPNoteTemplate5.docx**

    | | |
    | — | — |
    | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
    | _Demographics_ | |
    | _Chief Complaint (Reason for seeking health care)_ | |
    | _History of Present Illness (HPI)_ | |
    | _Allergies_ | |
    | _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
    | _Vital Signs_ | |
    | _Labs_ | |
    | _Medications_ | |
    | _Past Medical History_ | |
    | _Past Surgical History_ | |
    | _Family History_ | |
    | _Social History_ | |
    | _Health Maintenance/ Screenings_ | |
    | _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
    | _Diagnosis_ | |
    | _Differential Diagnosis_ | |
    | _ICD 10 Coding_ | |
    | _Pharmacologic treatment plan_ | |
    | _Diagnostic/Lab Testing_ | |
    | _Education_ | |
    | _Anticipatory Guidance_ | |
    | _Follow up plan_ | |
    | _Prescription_ | See Below (scroll down) |
    | _References_ | |
    | _Grammar_ | |

    | |
    | — |
    | EA#: 101010101 STU Clinic LIC# 10000000 |
    | Tel: (000) 555-1234 FAX: (000) 555-12222 |
    | Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

    Signature (with appropriate credentials):_____________________________________

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

    **## SoapNoterubric.docx**

    | | |
    | — | — |
    | Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
    | Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
    | History of the Present Illness (HPI) | **5 to >3 pts**<br>**Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)** |
    | Allergies | **2 to >1.5 pts**<br>**Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)** |
    | Review of Systems (ROS) | **2 to >1.5 pts**<br>**Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.** |
    | Labs | **4 to >2 pts**<br>**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)** |
    | Past Medical History | **3 to >2 pts**<br>**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current** |
    | Past Surgical History | **3 to >2 pts**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |

    | | |
    | — | — |
    | Family History | **3 to >2 pts**<br>**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.** |
    | Social History | **3 to >2 pts**<br>**Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation** |
    | Health Maintenance / Screenings | **3 to >2 pts**<br>**Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests** |
    | Physical Examination | **15 to >8 pts**<br>**Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint** |
    | Diagnosis | **5 to >3 pts**<br>**Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)** |
    | Differential Diagnosis | **5 to >3 pts**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
    | Pharmacologic treatment plan | **5 to >3 pts**<br>**Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.** |

    | | |
    | — | — |
    | Diagnostic / Lab Testing | **3 to >2 pts**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
    | Education | **3 to >2 pts**<br>**Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives** |
    | Anticipatory Guidance | **3 to >2 pts**<br>**Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))** |
    | Follow Up Plan | **2 to >1 pts**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
    | Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |

    | | |
    | — | — |
    | Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.** |

    **## nurs514CLsoap3.docx**

    · Patient is a 57 year female.

    · Patient comes in because she has noticed a strong foul smell in her urine.

    · Has no pain.

    · No known allergies to meds or anything

    · No surgeries

    · Only 2 natural labors

    · Doesn’t take an medications, just vitamins

    **_SOAP Note 3_**

    A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

    **Instructions:**

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

    For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

    | | |
    | — | — |
    | **S** = | Subjective data: Patient’s Chief Complaint (CC). |
    | **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
    | **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
    | **P** = | Plan: Treatment, diagnostic testing, and follow up |

    [Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/43383/files/3176310?wrap=1) [Download Click here to access and download the SOAP Note Template](https://stu.instructure.com/courses/43383/files/3176310/download?download_frd=1)

    **Submission Instructions:**

    · Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.

    · You must use the template provided. Turnitin will recognize the template and not score against it.

    · Your submission will be reviewed for plagiarism through Turnitin.

    ![null](https://www.sweetstudy.com/questions/nurs-514-cl-soap-3)

    ## image1.png

    **## SOAPNoteTemplate5.docx**

    | | |
    | — | — |
    | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
    | _Demographics_ | |
    | _Chief Complaint (Reason for seeking health care)_ | |
    | _History of Present Illness (HPI)_ | |
    | _Allergies_ | |
    | _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
    | _Vital Signs_ | |
    | _Labs_ | |
    | _Medications_ | |
    | _Past Medical History_ | |
    | _Past Surgical History_ | |
    | _Family History_ | |
    | _Social History_ | |
    | _Health Maintenance/ Screenings_ | |
    | _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
    | _Diagnosis_ | |
    | _Differential Diagnosis_ | |
    | _ICD 10 Coding_ | |
    | _Pharmacologic treatment plan_ | |
    | _Diagnostic/Lab Testing_ | |
    | _Education_ | |
    | _Anticipatory Guidance_ | |
    | _Follow up plan_ | |
    | _Prescription_ | See Below (scroll down) |
    | _References_ | |
    | _Grammar_ | |

    | |
    | — |
    | EA#: 101010101 STU Clinic LIC# 10000000 |
    | Tel: (000) 555-1234 FAX: (000) 555-12222 |
    | Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

    Signature (with appropriate credentials):_____________________________________

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

    **## SoapNoterubric.docx**

    | | |
    | — | — |
    | Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
    | Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
    | History of the Present Illness (HPI) | **5 to >3 pts**<br>**Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)** |
    | Allergies | **2 to >1.5 pts**<br>**Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)** |
    | Review of Systems (ROS) | **2 to >1.5 pts**<br>**Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.** |
    | Labs | **4 to >2 pts**<br>**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)** |
    | Past Medical History | **3 to >2 pts**<br>**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current** |
    | Past Surgical History | **3 to >2 pts**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |

    | | |
    | — | — |
    | Family History | **3 to >2 pts**<br>**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.** |
    | Social History | **3 to >2 pts**<br>**Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation** |
    | Health Maintenance / Screenings | **3 to >2 pts**<br>**Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests** |
    | Physical Examination | **15 to >8 pts**<br>**Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint** |
    | Diagnosis | **5 to >3 pts**<br>**Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)** |
    | Differential Diagnosis | **5 to >3 pts**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
    | Pharmacologic treatment plan | **5 to >3 pts**<br>**Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.** |

    | | |
    | — | — |
    | Diagnostic / Lab Testing | **3 to >2 pts**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
    | Education | **3 to >2 pts**<br>**Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives** |
    | Anticipatory Guidance | **3 to >2 pts**<br>**Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))** |
    | Follow Up Plan | **2 to >1 pts**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
    | Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |

    | | |
    | — | — |
    | Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.** |

  • [Solved] nurs 514 CL discussion 6

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    – 2 years ago **files (1)** – ## nurs514CLdiscssion6.docx **## nurs514CLdiscssion6.docx** Patient was a female that has a foul urine smell but no pain. Describe your clinical experience for this week. · Did you face any challenges, any success? If so, what were they? · Describe the assessment of a p…

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    – 2 years ago

    **files (1)**

    – ## nurs514CLdiscssion6.docx

    **## nurs514CLdiscssion6.docx**

    Patient was a female that has a foul urine smell but no pain.

    Describe your clinical experience for this week.

    · Did you face any challenges, any success? If so, what were they?

    · Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.

    · Mention the health promotion intervention for this patient.

    · What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?

    · Support your plan of care with the current peer-reviewed research guideline.

    **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.

    **## nurs514CLdiscssion6.docx**

    Patient was a female that has a foul urine smell but no pain.

    Describe your clinical experience for this week.

    · Did you face any challenges, any success? If so, what were they?

    · Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.

    · Mention the health promotion intervention for this patient.

    · What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?

    · Support your plan of care with the current peer-reviewed research guideline.

    **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.

  • [Solved] wwwwwwwwwwWeekly Clinical Experience 6

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    Describe your clinical experience for this week as a student nurse practitioner in women's health clinic – Did you face any challenges, any success? If so, what were they? – Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possibl…

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    Assignment Prompt & Instructions

    Describe your clinical experience for this week as a student nurse practitioner in women's health clinic

    – Did you face any challenges, any success? If so, what were they?
    – Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
    – Mention the health promotion intervention for this patient.
    – What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?
    – Support your plan of care with the current peer-reviewed research guideline.

    **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.

    – 2 years ago

  • [Solved] WEEK 6 DISCUSSION & REFLECTION

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    In-depth study guidance and analytical solution covering WEEK 6 DISCUSSION & REFLECTION.

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  • [Solved] workarea

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  • [Solved] writing

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  • [Solved] Health Assessment

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    – 2 years ago **files (1)** – ## mhsimone12.docx **## mhsimone12.docx** Respond to these two posts with 75-80 words. No AI. Will go through Turnitin.com **#1** "According to the Centers for Disease Control and Prevention (CDC), more than 34 million people in the United States (U.S.) have diabetes, a…

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    – 2 years ago

    **files (1)**

    – ## mhsimone12.docx

    **## mhsimone12.docx**

    Respond to these two posts with 75-80 words. No AI. Will go through Turnitin.com

    **#1**

    "According to the Centers for Disease Control and Prevention (CDC), more than 34 million people in the United States (U.S.) have diabetes, and 1 in 5 of those individuals don't know they have it. Diabetes takes a heavy toll on the AA/black population and older adults. Almost one-fifth of AA/black individuals and one-fourth of elderly people have diabetes in Alabama" (Alabama Public Health, 2024). For this discussion, we will focus on the vulnerability of the black population in this region. The town of Phenix City falls into the county of Russell, and the Russell County Health Department is nestled within this community. The health department assists with monitoring chronic diseases such as diabetes. They offer programs that could assist an individual in obtaining free diabetic monitoring equipment and provide a registered nurse to help individuals achieve their goals at no cost. The coaching given to those diagnosed with diabetes equips the individual with the knowledge necessary to practice autonomy and play a more active role in their care plan. While this offers great tools for individuals affected by diabetes, for the programs to have the best patient outcomes, the diagnosed individual should have a healthcare provider for a continuum of care. It is the lack of access to care within this community that places these individuals at greater risk of developing complications from this disease. "Primary Care Physicians in Russell County have a ratio of 5,870 patients to one provider" (County Health Ranking & Roadmaps, 2025). Looking at the state of Alabama's ratio of "1,570 patients to one provider" (County Health Ranking & Roadmaps, 2025), we cannot help but notice the drastic differences between those numbers. How could one provider efficiently take care of so many patients? Unfortunately, my guess is they cannot.

    The most significant barrier to improving the health of this vulnerable population is the lack of resources/access to care within this community. Next, we must look at the poverty level within this community. "The poverty rate in Phenix City, Alabama is 23.8%, about 1.5 times the rate in Alabama" (Census Reporter, 2023). Sadly, we still witness inequalities within the healthcare systems towards certain groups of people, which causes distrust within specific populations. Many locals remember The Untreated Syphilis Study at Tuskegee, where "the study was supposed to observe the natural history of untreated syphilis. As part of the study, researchers did not collect informed consent from participants. They also did not offer treatment, even after it was easily available" (CDC, n.d.). This study started in 1932 and ended in 1972. The study aided in the distrust of healthcare providers among locals within the community. "The percentage of individuals that completed high school in Russell was "85% compared to 88%" (County Health Ranking & Roadmaps, 2025) for the state of Alabama's average. The U.S. has an average "89% high school completion rate" (County Health Ranking & Roadmaps, 2025).

    **#2**

    In Fort Payne Alabama, there are multiple vulnerable populations. For this discussion, we will focus on the population living in poverty. According to the U.S. Census Bureau in Fort Payne, there is just under 24 percent of the population that live in poverty (U.S. Census Bureau, n.d.). There are numerous resources available for this population.

    Resources available include the Dekalb County Health Department which offers free or low-cost healthcare services (Alabama Public Health, n.d.). Another resource is numerous community health clinics such as Northeast Alabama Health Services which offers health care on a sliding fee scale (Free Clinics, n.d.). The Dekalb County Community Action Agency assists with food, housing, and other basic needs (Community Action Agency of Northeast Alabama, n.d.). The Dekalb County Department of Human Resources provides a supplemental nutrition assistance program to help with getting food (Alabama Department of Human Resources, n.d.). The Salvation Army, a distinct branch of the Christian church, shares core Christian beliefs and focuses on promoting Christianity, education, poverty relief, and other charitable works by providing food, clothing, and other support (The Salvation Army International, n.d.). The Marked For Life Ministries Hope Center in DeKalb County offers spiritual, practical, and emotional support, including meals, clothing, job resources, and life skills training, emphasizing hope and restoration, particularly for those facing homelessness, addiction, and food insecurity (Marked for Life Ministries, n.d.). For assistance with essential needs and other resources, dial 2-1-1. This free and confidential service provides access to local organizations offering support for food, shelter, healthcare, job training, disaster relief, and more (211 Connects Alabama, n.d.).

    With the resources mentioned above, there appears to be an adequate amount of access to healthcare, social services, and support for those who live in poverty in Fort Payne. In Fort Payne schools score above the state average, with two elementary schools earning A's. While middle and high school scores dipped slightly, the district excels in growth, college readiness, and graduation rates (Staff Reports, 2024). A million-dollar grant will fund a new vocational training center in Fort Payne, focused on construction, electric vehicle, and aviation technologies, preparing students and adults for in-demand jobs (ADECA, 2021). Taking all this into consideration it appears to show that the quality of public schools and the availability of vocational training outside of college is appropriate. Fort Payne has fewer police officers per capita than both the state and national averages, suggesting potentially inadequate coverage (Areavibes, n.d.).

    Two major religious organizations in Fort Payne are active in improving the health of the vulnerable. The first is Minvale Life Center, which offers wellness programs and resources focused on mental, emotional, and physical health, supporting personal growth and recovery through workshops, counseling, and resource connections (7 Cups, n.d.). Secondly, the Marked For Life Ministries Hope Center strengthens the Fort Payne community by offering spiritual, emotional, and practical support, including meals, clothing, job resources, and life skills training, with a focus on those facing homelessness, addiction, and food insecurity.

    Vulnerable populations in Fort Payne likely face health barriers like poverty, limited healthcare access, food insecurity, housing instability, transportation issues, education disparities, social isolation, substance abuse, mental health stigma and access problems, and lack of awareness of resources. Addressing the health disparities faced by vulnerable populations in Fort Payne requires focusing on several key areas. Increased funding for health programs and social services is essential. Fostering strong leadership is crucial. Improving education and health literacy, while being culturally sensitive, can empower individuals to make healthier choices. Expanding access to essential resources, including healthy food and safe housing, is vital. Combating stigma, improving data collection, and promoting collaboration and communication among organizations are also critical for progress.

    **## mhsimone12.docx**

    Respond to these two posts with 75-80 words. No AI. Will go through Turnitin.com

    **#1**

    "According to the Centers for Disease Control and Prevention (CDC), more than 34 million people in the United States (U.S.) have diabetes, and 1 in 5 of those individuals don't know they have it. Diabetes takes a heavy toll on the AA/black population and older adults. Almost one-fifth of AA/black individuals and one-fourth of elderly people have diabetes in Alabama" (Alabama Public Health, 2024). For this discussion, we will focus on the vulnerability of the black population in this region. The town of Phenix City falls into the county of Russell, and the Russell County Health Department is nestled within this community. The health department assists with monitoring chronic diseases such as diabetes. They offer programs that could assist an individual in obtaining free diabetic monitoring equipment and provide a registered nurse to help individuals achieve their goals at no cost. The coaching given to those diagnosed with diabetes equips the individual with the knowledge necessary to practice autonomy and play a more active role in their care plan. While this offers great tools for individuals affected by diabetes, for the programs to have the best patient outcomes, the diagnosed individual should have a healthcare provider for a continuum of care. It is the lack of access to care within this community that places these individuals at greater risk of developing complications from this disease. "Primary Care Physicians in Russell County have a ratio of 5,870 patients to one provider" (County Health Ranking & Roadmaps, 2025). Looking at the state of Alabama's ratio of "1,570 patients to one provider" (County Health Ranking & Roadmaps, 2025), we cannot help but notice the drastic differences between those numbers. How could one provider efficiently take care of so many patients? Unfortunately, my guess is they cannot.

    The most significant barrier to improving the health of this vulnerable population is the lack of resources/access to care within this community. Next, we must look at the poverty level within this community. "The poverty rate in Phenix City, Alabama is 23.8%, about 1.5 times the rate in Alabama" (Census Reporter, 2023). Sadly, we still witness inequalities within the healthcare systems towards certain groups of people, which causes distrust within specific populations. Many locals remember The Untreated Syphilis Study at Tuskegee, where "the study was supposed to observe the natural history of untreated syphilis. As part of the study, researchers did not collect informed consent from participants. They also did not offer treatment, even after it was easily available" (CDC, n.d.). This study started in 1932 and ended in 1972. The study aided in the distrust of healthcare providers among locals within the community. "The percentage of individuals that completed high school in Russell was "85% compared to 88%" (County Health Ranking & Roadmaps, 2025) for the state of Alabama's average. The U.S. has an average "89% high school completion rate" (County Health Ranking & Roadmaps, 2025).

    **#2**

    In Fort Payne Alabama, there are multiple vulnerable populations. For this discussion, we will focus on the population living in poverty. According to the U.S. Census Bureau in Fort Payne, there is just under 24 percent of the population that live in poverty (U.S. Census Bureau, n.d.). There are numerous resources available for this population.

    Resources available include the Dekalb County Health Department which offers free or low-cost healthcare services (Alabama Public Health, n.d.). Another resource is numerous community health clinics such as Northeast Alabama Health Services which offers health care on a sliding fee scale (Free Clinics, n.d.). The Dekalb County Community Action Agency assists with food, housing, and other basic needs (Community Action Agency of Northeast Alabama, n.d.). The Dekalb County Department of Human Resources provides a supplemental nutrition assistance program to help with getting food (Alabama Department of Human Resources, n.d.). The Salvation Army, a distinct branch of the Christian church, shares core Christian beliefs and focuses on promoting Christianity, education, poverty relief, and other charitable works by providing food, clothing, and other support (The Salvation Army International, n.d.). The Marked For Life Ministries Hope Center in DeKalb County offers spiritual, practical, and emotional support, including meals, clothing, job resources, and life skills training, emphasizing hope and restoration, particularly for those facing homelessness, addiction, and food insecurity (Marked for Life Ministries, n.d.). For assistance with essential needs and other resources, dial 2-1-1. This free and confidential service provides access to local organizations offering support for food, shelter, healthcare, job training, disaster relief, and more (211 Connects Alabama, n.d.).

    With the resources mentioned above, there appears to be an adequate amount of access to healthcare, social services, and support for those who live in poverty in Fort Payne. In Fort Payne schools score above the state average, with two elementary schools earning A's. While middle and high school scores dipped slightly, the district excels in growth, college readiness, and graduation rates (Staff Reports, 2024). A million-dollar grant will fund a new vocational training center in Fort Payne, focused on construction, electric vehicle, and aviation technologies, preparing students and adults for in-demand jobs (ADECA, 2021). Taking all this into consideration it appears to show that the quality of public schools and the availability of vocational training outside of college is appropriate. Fort Payne has fewer police officers per capita than both the state and national averages, suggesting potentially inadequate coverage (Areavibes, n.d.).

    Two major religious organizations in Fort Payne are active in improving the health of the vulnerable. The first is Minvale Life Center, which offers wellness programs and resources focused on mental, emotional, and physical health, supporting personal growth and recovery through workshops, counseling, and resource connections (7 Cups, n.d.). Secondly, the Marked For Life Ministries Hope Center strengthens the Fort Payne community by offering spiritual, emotional, and practical support, including meals, clothing, job resources, and life skills training, with a focus on those facing homelessness, addiction, and food insecurity.

    Vulnerable populations in Fort Payne likely face health barriers like poverty, limited healthcare access, food insecurity, housing instability, transportation issues, education disparities, social isolation, substance abuse, mental health stigma and access problems, and lack of awareness of resources. Addressing the health disparities faced by vulnerable populations in Fort Payne requires focusing on several key areas. Increased funding for health programs and social services is essential. Fostering strong leadership is crucial. Improving education and health literacy, while being culturally sensitive, can empower individuals to make healthier choices. Expanding access to essential resources, including healthy food and safe housing, is vital. Combating stigma, improving data collection, and promoting collaboration and communication among organizations are also critical for progress.

  • [Solved] Week 6 Reflection

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  • [Solved] week 8

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    Follow these guidelines when completing each component of the Collaboration Café. 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. – Reflect on your learning expe…

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    Follow these guidelines when completing each component of the Collaboration Café. 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.

    – Reflect on your learning experience in this course. Which concepts stood out to you and made an impact? How do you envision using these concepts in your future nursing practice as a master’s prepared nurse practitioner?
    – Describe how course learning activities and assignments will help you achieve _Program Outcome 4: Integrate professional values through scholarship and service in health care_.
    – Describe how course assignments or activities will help you achieve ONE of the sub-competencies from the advanced-level nursing education competencies from _AACN Essentials Competency 4.1 Advance the Scholarship of Nursing_.

    – 4.1h Apply and critically evaluate advanced knowledge in a defined area of nursing practice.
    – 4.1i Engage in scholarship to advance health.
    – 4.1j Discern appropriate applications of quality improvement, research, and evaluation methodologies.
    – 4.1k Collaborate to advance one’s scholarship.
    – 4.1l Disseminate one’s scholarship to diverse audiences using a variety of approaches or modalities.
    – 4.1m Advocate within the interprofessional team and with other stakeholders for the contributions of nursing scholarship.

    – 2 years ago

  • [Solved] Weekly Clinical Experience 6

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    **Describe your clinical experience for this week.** **MUST BE ON PEDIATRIC PATIENT** – **Did you face any challenges, any success? If so, what were they?** – **Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differentia…

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    **Describe your clinical experience for this week.**

    **MUST BE ON PEDIATRIC PATIENT**

    – **Did you face any challenges, any success? If so, what were they?**
    – **Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.**
    – **Mention the health promotion intervention for this patient.**
    – **What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?**
    – **Support your plan of care with the current peer-reviewed research guideline.**

    **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.**

    – 2 years ago