Soap note Study guides, Class notes & Summaries

Week 3: Focused SOAP Note and Patient Case Presentation College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum Introduction Each mental intervention is based on the evidence gathered during the initial interview with the patient; each patient's therapy begins with a thorough medical and mental health evaluation, the incorporation of trust, and a dialogue of past mental health history, substance misuse history, family mental health history, and so forth...

what is the primary function of a medical scribe? - create the medical note what is the preferred format for the creation of the medical note? - subjective, objective, assessment, plan (soap) "present time" pt details are summarized by using what format - OPQRST all current procedural terminology (CPT) codes must be justified by what appropiate coding mechanisms - international classification of disease (ICD) what patient history is outlined in the PMHx - medical history what scribing i...

NSG 6435 Comprehensive SOAP Note Tommy Acker V5

WOMEN’S HEALTH MINI SOAP NOTES A 25-year-old woman comes to the clinic complaining of increased vaginal discharge, milky gray in color with a "fishy" odor that both she and her husband have noticed. A wet smear is performed and the presence of "clue cells" confirmed. Which type of infection does the nurse suspect? 1 Candidiasis 2 Trichomoniasis 3 Bacterial vaginosis 4 Group B Streptococcus - ANS -Bacterial vaginosis Signs of bacterial vaginosis include a milky gray vaginal...

Name: Carolyn Cross Date: 3/18/2017 Time: 21:00am elmdtn Patient Encounter # 4140505 Age: 41 years Sex: Female CC: This 41-year-old male presents a chronic cough. She said, “My throat is painful, I cough frequently. There seems to be nothing to relieve it when I started to cough.” HPI: Carolyn Cross confirms that coughing started almost four weeks ago after failing to wear a sweater, during one cold morning when attending a job. Carolyn Cross added that chronic coughing started one wee...

NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation/NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation/NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation/NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation

:Section 1 Patient Initials: J.A. Age: 58 y/o Gender: Male Race: Caucasian ”.Chief complaint: “I’ve been having some chest discomfort · :HPI · OLDCARTS o J.A. is a 58 y/o healthy man presenting to care provider with a o complaint of recent episodes of burning chest discomfort X 4 days. Rating substernal pain 4-5/10 at its worst, radiating into his neck. Current pain of 1-2/10. Borderline-obese. Well controlled HTN, on Lopressor, and borderline lipid abnormality. Recent stres...

HEENT SOAP NOTE with complete solution HEENT SOAP NOTE Jewel Concepcion United States University MSN 572 Advanced Physical Assessment Dr. Sherian Wilmot-Carter March 27, 2023

NSG 6430 Week 8 SOAP NOTE 2024 with complete solution; South University CC: “I have a couple of painless lumps on my right breast.” HPI: A 51-year-old white female patient presents with a chief complaint of two painless right-breast lumps that she detected four months ago. She denies any recent or past breast trauma, breast discharge, bleeding, or overlying skin changes.

NSG 6430 Week 4 SOAP NOTE 2024 with complete solution; South University HPI: The patient reports first noticing the lump approximately 3 weeks ago. She denies any associated pain, redness, discharge, or changes in the skin over the lump. She has not noticed any similar lumps elsewhere on her body. The patient denies any recent trauma or injury to the breast area.