Case Study: Postmenopausal Bleeding Instructions Thelma Smith is a 58-year-old African American female who presents to the office with the complaint of brown discharge for several days last week. Her medical history is remarkable for type 2 diabetes somewhat controlled with glipizide and metformin (last A1C 7.5). She is a G0, having never been able […]
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Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.” HPI: This is the symptom analysis section of your note. Thorough documentation in this section
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Case Study: Missed Period Instructions Juanita Morales is a 47-year-old G5. P5 LC 6, Hispanic female who presents to the office complaining of lower abdominal cramping, and urinary leakage for past day. She states the abdominal cramping, suprapubic, started several hours ago, is sharp, intermittent, and getting more frequent and painful. She tried Motrin but
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Case Study: Chlamydia, Trichomoniasis ,Bacterial Vaginosis Instructions Review the Learning Resources for this week, with a focus on the media program related to basic microscope skills. Also, consider revisiting the media programs found in Week 1 Learning Resources. Carefully review the clinical guideline resources specific to your assigned case study. Use the Focused SOAP Note
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GYNHistory and Physical Template ChiefComplaint: HPI – First sentence should include age, parity, LMP and present problem (details about cc andotherrelevant information). MenstrualHistory Menarche,duration,flowandcyclelengthofmenses,IMB(intermenstrual bleeding), or contact bleeding, dysmenorrheal, PMS,climacteric GynecologicHistory Breasthistory–historyofbreastdisease,breastfeeding,theuseofSBE(Self Breast Exam),last mammogram(if applicable) Previousgynsurgery(caninclude insurgical history) Historyofinfertility HistoryofDES(diethylstilbestrol)usebypatient’smother Lastpap smear– historyof abnormal pap Contraceptive/SexualHistory Currentmethod/patients’satisfactionwithcurrentmethod PastMethods Currentsexuallyactivity Numberof Partners Newpartner
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Paget Disease of the Nipple-SOAP Note Instructions This is a soap note to be done on a female patient with a primary diagnosis of Paget Disease of the Nipple Differential diagnosis: Eczema, and psoriasis. INCLUDE ICD 10 CODE WITH DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS Use both the templates attached. NRNP 6552 Focused SOAP Note Template WK4
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SOAP Note 2 template (Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C Soap Note # ____ Main Diagnosis ______________ PATIENT INFORMATION Name: Age: Gender at Birth: Gender Identity: Source: Allergies: Current Medications: PMH: Immunizations: Preventive Care: Surgical History: Family History: Social History: Sexual Orientation:
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Hypertension Instructions Must use the sample template for your soap note, keep this template for when you start clinicals. Late Assignment Policy Assignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get grade of 0 (zero). No exceptions Follow the MRU Soap Note Rubric
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Bacterial Vaginosis Instructions This paper is for a SOAP Note for a female patient with Bacterial Vaginosis The rubric is attached as well as the template. Please use the template for completing the assignment. References must be no older than 3 years. Solution Patient Demographics Age: 21 years Race: African American Gender: Female Insurance: Private
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INTERACTION BETWEEN NURSE INFORMATICISTS AND OTHER SPECIALISTS Instructions Nature offers many examples of specialization and collaboration. Ant colonies and bee hives are but two examples of nature’s sophisticated organizations. Each thrives because their members specialize by tasks, divide labor, and collaborate to ensure food, safety, and general well-being of the colony or hive. Of course,
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