08 Oct This is an assignment. A new soap note template an
This is an assignment. A new soap note template and example will be uploaded. My preceptor has to sign the SOAP Note and on the new Template it provides that spot. The patient is a patient I saw in the clinic and the following is the assessment. 67 year old female presents to clinic with increase shortness of breath and weakness. Patient is pale, using accessory muscle and pursed lip breathing. Patient denies any cough. Patient is receiving chemotherapy for left sided breast cancer. VS: Temp 97.9, HR 125, RR 20, BP 115/77mm/HG, wt 120 lbs, Ht 65 inches (5’4”) BMI 20.6, Oxygen 94 on RA History: nonsmoker, HTN, Hypercholesterolemia, Lower extremity edema/venous insuffiency, Osteoarthritis, Left Breast Cancer Surgical Hx: total hysterectomy Medications: Dexamethasone 4 mg 3 tabs po bid on days 2 and 3 of cancer tx Metoclopramide HCL 10 MG 1 tab tid Aprepitant 80 & 125 mg: 125 mg 1 tab daily one hour before chemo, 80 mg 1 tab on day 2 and 3 in the AM (Nausea) Metoprolol Succinate ER 50 mg 1 tab in the AM Hyzaarr 100-25 mg 1 tab in the AM Aspirin 81 MG 1 tab in the AM Hydralazine HCL 50 MG 1 tab with food bid Diclofenac Sodium 50 MG 1 tab with food or milk bid prn pain Hydrochlorothiazide 25 MG 1 tab in the AM Pravastatin Sodium 40 MG 1 tab QHS Magnesium Oxidie 400 MG 1 tab in the AM Spironolactone 25 MG 1 tab in the AM Gabapentin 100 MG 2 caps tid Zofran 2 MG 1 tab daily General Appearance: alert/fatigued appearing Oral Cavity: mucosa moist, light pink Throat: clear Neck/Thyroid: Neck supple, full range of motion, no cervical lymphadenopathy Skin: no suspicious lesions, pale, warm and dry Heart: Tachycardia Lungs: cleat to auscultation A/P bilaterally Abdomen: flat, normal bowel sounds, soft and nontender Back: full range of motion Extremities: bilateral nonpitting edema to the lower extremities Neurologic: nonfocal Psych: alert, oriented, cooperative with exam We sent patient over for a CT scan specious for pulmonary embolism and possible cancer metastatic to lung. Also repeating labs due to possible anemia cause by chemotherapy; patient may need a blood transfusion if Hbg and Hct are low. If blood counts are low chemotherapy will have to be place on hold until counts are stable. Patient will also be evaluated for oxygen therapy in home. Just for you: Post CT we found patient have several small pulmonary embolisms, and the her breast cancer has metastases to the lung. We also discussed with the patient she was in need of a blood transfusion; which she declined. Assignment 1: Practicum Experience – Episodic SOAP Note #1 In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes. All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Notes, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Notes using SAFE ASSIGN. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies. To Prepare: • Review the Episodic SOAP Note Exemplar provided in this week’s Resources in preparation for this Assignment. • Use the Episodic SOAP Note Template to complete this Assignment. After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note: • Subjective: What details did the patient provide regarding his or her personal and medical history? • Objective: What observations did you make during the physical assessment? • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? • Reflection notes: What would you do differently in a similar patient evaluation? • Please Note: Your Episodic SOAP Note Assignment must be signed by Day 7 of Week 3. By Day 7 of Week 3 This Assignment is due. You will submit two files for the Week 3 Episodic SOAP Note, including a Word document and pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 3. Submission and Grading Information Subjective(25points) ● CC 1 ● Pertinent positives LOCATES 10 ● Pertinent negatives(fromROS) 10 ● Pertinent PMH,SH,andFH 3 ● Medications and drug/food allergies are not included 1 Objective(20points) ● VS including BMI 2 ● Heart and lungs 1 ● Systems or specialty exam techniques that are not necessary to arrive a a diagnosis are included. 5 ● Systemsorspecialtyexamtechniquesthatarenecessarytoarriveatyourdiagnosisareomitted. 10 ● Diagnostictestresults 2 Assessment–10pointsfor each priority diagnosis(total30points) 30 Plan(15points) ● Medications discontinued(“d/clisinopril10mgdaily”) 1 ● Medications started(“startAvapro 150mgdaily”) 2 ● Alternative therapies if appropriate(1point) 1 ● Health Promotion strategies–patient/family education 3 ● Disease Prevention strategies with time frame if appropriate 3 ● Diagnostic tests ordered with timeframe (now,in2weeks,priortof/uvisitin3months) 3 ● Referrals or consultations if appropriate 1 ● Follow-up interval 1 Reflectionnotes(10points) ● What did you learn from this experience?Any ah-ha’s? 10 Totalpoints 100/100 • Preceptor must sign all SOAP notes before submission. Any SOAP note not including the preceptor signature will not be graded, or will be graded as a late submission if necessary.
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