Nursing

Subjective Documentation in Provider Notes Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each […]

Pulmonary— Lungs are clear to auscultation and percussion bilaterally Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines) A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines). Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Place Your Order Here!

Episodic/Focused SOAP Note Exemplar Focused SOAP Note for a patient with chest pain S. CC: “Chest pain”  HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The

Recommend antitussive treatment at night to help with his sleep. Danny should be referred for an allergy test to rule out allergies as well as a lung function test to rule out asthma. He should receive a strep culture to rule out strep throat. I recommend antitussive treatment at night to help with his sleep

  Assessment My differentials include acute viral rhinopharyngitis. strep throat, allergic rhinitis, acute otitis media, allergies and asthma My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting the ears, upper respiratory tract and lymphatic region. Plan Danny will receive a strep throat culture to rule out strep throat. 10

Cardiovascular: S1, S2, no murmurs, gallops or rubs. Mild tachycardia Respiratory: Chest is symmetrical with respirations. Increased respiratory rate. Audible coarse crackles in upper airway; bronchovesicular bilaterally, clears with cough. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FEV1:3.15L, FVC 3.91L( FEV1/FVC: 80.5%) • General Survey: Fatigued appearing young boy seated

Cardiovascular: Denies chest pain or chest discomfort Objective Mr. Rivera is pleasant and cooperative fatgued appearing young boy seated upright on the examination table. He is in no acute distress. He is alert. His speech is clear and coherent. He maintains eye contact throught the interview and examination. He offers information freely and without contradiction.

Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Self-Reflection Student Survey Documentation / Electronic Health Record https://www.coursehero.com/file/50185069/Cough-Shadow-Health-Documentationpdf/ Th is s tud y r eso urc e w as sha red vi a C ou rse He ro. co m 11/11/19, 3:44 PMFocused Exam: Cough | Completed | Shadow Health Page 2 of

Review of the Systems Constitutional: Denies fever, denies chillis, denies weigh loss or gain, denies night sweats. Reports feeling “kind of tired” HEENT: Denies ear popping, Reports history of frequent ear infections. Denies ear surgery or ear tubes. Denies headaches. Denies nosebleeds, Reports runny nose, denies vision problems, Denies dizziness, denies watery eyes, denies eye