Laboratory for Diagnosis, Symptom and Illness Management

Soap Note 1 Acute Conditions Due by 02/06/2021 at 11:59 pmSoap Note 1 Acute ConditionsPick any Acute Disease from Weeks 1-5   (  ACUTE BRONCHITIS )Must use the sample template for your soap note, keep this template for when you start clinicals.Late Assignment PolicyAssignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get a grade of 0. No exceptionsFollow the MRU Soap Note Rubric as a guideUse APA format and must include a minimum of 2 Scholarly Citations.Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)Turn it in Score must be less than 25% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.Soap Note 1 Acute ConditionsAssignmentSoap Note 1 Acute Conditions (10 points)Follow the MRU Soap Note Rubric as a guide:Use APA format and must include mia minimum of 2 Scholarly Citations.Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)Turn it in’ s Score must be less than 25% or will not be accepted for credit; it must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated and will receive a grade of 0 (zero) with no resubmissions allowed.Please see College Handbook regarding Academic Misconduct Statement.Must use the sample templates for your soap note. Keep this template for when you start clinicals.The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.(Student Name)Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site:Clinical Instructor: Patricio Bidart MSN, APRN, FNP-CSoap Note # ____ Main Diagnosis ______________PATIENT INFORMATIONName:Age:Gender at Birth:Gender Identity:Source:Allergies:Current Medications:·PMH:Immunizations:Preventive Care:Surgical History:Family History:Social History:Sexual Orientation:Nutrition History:Subjective Data:Chief Complaint:Symptom analysis/HPI:The patient is …Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )CONSTITUTIONAL:NEUROLOGIC:HEENT:RESPIRATORY:CARDIOVASCULAR:GASTROINTESTINAL:GENITOURINARY:MUSCULOSKELETAL:SKIN:Objective Data:VITAL SIGNS:GENERAL APPREARANCE:NEUROLOGIC:HEENT:CARDIOVASCULAR:RESPIRATORY:GASTROINTESTINAL:MUSKULOSKELETAL:INTEGUMENTARY:ASSESSMENT:(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)Main Diagnosis(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.Differential diagnosis (minimum 3)—PLAN:Labs and Diagnostic Test to be ordered (if applicable)· -· -Pharmacological treatment:-Non-Pharmacologic treatment:Education (provide the most relevant ones tailored to your patient)Follow-ups/ReferralsReferences (in APA Style)ExamplesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010(25th ed.). Print (The 5-Minute Consult Series).

 

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