How can we identify health risks, strengths, and needs in our comprehensive health assessment?
How can we identify health risks, strengths, and needs in our comprehensive health assessment?
Give two examples with rationale for each.
NU609 Advanced Health Assessment
Unit 2 Discussion
Health History
Consider performing a health history on someone that may not be able to provide you with answers, such as an infant, child, an elderly person, a developmentally disabled individual, or patients who speak a language you do not know.
What strategies would you employ to obtain a complete the health history?
Provide a rationale for why you think these strategies would be effective.
NU609 Advanced Health Assessment
Unit 3 Discussion
Skin Conditions
T. R. (a 23-year-old female) presents to the local health clinic with complaints of two red, scaly patches on her Right arm.
HPI: Started about two weeks ago. She states that the first lesions appeared to be poison ivy. After the vesicles cleared, the itching and scaling remained. She now has new lesions over her left eyebrow, and a small patch appears over her right upper lip. She states that the lesions have not cleared with over-the-counter medications. She believes she has used steroid cream, antibacterial cream, and anti-itch cream.
Questions
What other questions regarding her HPI would you like to ask?
What additional history would you like to obtain from R.H? (Be comprehensive in this response; you have no past medical history for this client.)
This is how the rash appears on physical examination:
Unit 3 DB image.png
What specifically would you assess for on physical exam? How would you document the lesions?
What characteristics would you look for or questions would you ask to ascertain risk of skin cancer?
What education would you provide related to skin cancer health promotion and screening guidelines?
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
NU609 Advanced Health Assessment
Unit 4 Discussion
Nasal Conditions
A 35-year-old woman with a history of asthma is complaining of nasal itching, sneezing, and rhinorrhea. She states her symptoms are worse in the spring and fall. She does have difficulty sleeping due to congestion. She does not smoke but does have 2 cats in the home. She does appear tired but no respiratory distress. Her vital signs are T98.8, R18, P88 and BP 128/80. Nasal turbinates are swollen, boggy and pale, bluish gray. Thin watery secretions are seen.
Based on this information what is the subjective data?
What information is the objective data?
Give an example of 2 questions you may want to ask this patient.
NU609 Advanced Health Assessment
Unit 5 Discussion
Thoracic Conditions
Consider factors (such as disease process, musculoskeletal changes, or environmental risks) that can influence the evaluation of the lungs and thorax and,
Discuss how you will adjust the H&P around these factors.
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
NU609 Advanced Health Assessment
Unit 6 Discussion
Cardiac Conditions
C. T. a 48-year-old male patient presents for a checkup. He admits it has been 4 years since he has been seen by a medical professional and at that time was diagnosed with an upper respiratory illness. He did have his blood pressure taken a year ago at his employer’s health fair and was told it was a “little high”.
He has had no major illness or chronic diseases. He has no known allergies and does not take any regular medication.
His family history shows that is father died of a heart attack at age 68, his mother is alive and well at age 72, he has a 50-year-old brother with depression and alcoholism, and one son who is healthy at age 24. He did have a maternal uncle with prostate cancer.
On review of systems, he has occasional headaches, experiences shortness of breath when he walks upstairs, and gets up once a night to urinate.
What should the major objectives of this health maintenance visit be?
What conditions, risk factors, and health related behaviors should be screened for during this visit?
What are the common causes of morbidity and mortality for 48-year-old men in the United States?
NU609 Advanced Health Assessment
Unit 7 Discussion
Breast Exams
A 32-year-old female presents for an evaluation of a lump in her right breast that she found on breast self-examination. The lump is found to be 2cm in size, firm, and mobile. No Adenopothy noted.
What are two questions you would ask this patient?
What are two risk factors would you want to assess for?
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
NU609 Advanced Health Assessment
Unit 8 Discussion
Eating Disorders
Today in the office you encounter a patient with an eating disorder such as anorexia or bulimia.
Discuss how you would approach the history and physical exam considering this information.
Identify specific subjective and objective data you would obtain during the visit and why those components are important and how they relate to the eating disorder.
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
Reply to at least TWO of your classmates.
NU609 Advanced Health Assessment
Unit 9 Discussion
Cancer Screening
Find two screening guidelines for testicular cancer or prostate cancer.
Discuss the similarities/differences in the screening guidelines and find available resources to help encourage adherence to screening guidelines in the target population.
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
NU609 Advanced Health Assessment
Unit 10 Discussion
Vaginal Conditions
You have a 28-year-old female in the clinic with a complaint of an offensive and fishy-smelling, abnormal vaginal discharge. She denies a history of STDs. She reports getting yeast infections on two occasions. Her last infection was a year ago. She used OTC medication and reported relief. Reports that she is married and has not had any other sex partners. Otherwise, she is healthy.
What two diagnostic/laboratory procedures would you order to evaluate her condition?
Discuss your rationale (document), normal findings or range for the procedures, teachings associated with the procedures (e.g., NPO, fasting, etc,).
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
NU609 Advanced Health Assessment
Unit 11 Discussion
Ankle Injuries
A 20-year-old male presents with an inversion injury of his right ankle that occurred while playing soccer. His ankle is swollen, but he can bear weight and has no focal tenderness and no ligament laxicity.
What testing might you want to order for this patient?
What would be the initial therapy for this type of injury?
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
NU609 Advanced Health Assessment
Unit 12 Discussion
Neurological Evaluation
A 60-year-old man is brought to the ER by ambulance because of slurred speech and left side weakness. His wife states they went to bed at 11pm and woke up at 5am when she noticed his symptoms. He is right handed with a history of coronary artery disease, hypertension, and hypercholesterolemia and a heart attack at age 50. He currently is unable to move his left arm and leg. He had an episode of amaurosis fugux (blindness)in his right eye one month ago that lasted for 5 minutes. Around 3 months ago his wife states he had bilateral pain in his legs while they were on a walk that lasted about 15 minutes. He is taking a baby aspirin a day an ACE inhibitor, and statin as well. He does have a history of alcohol use and smoking in the past but stopped after his heart attack. His blood pressure is 195/118 Pulse 106, Respiratory rate 18, Temperature 99.8, o2 sat is 97% on room air. Although his pupils are equal and reactive, and the ocular movements are intact, he is unable to turn his eyes voluntarily toward the left side. The neck is supple, there is no jugular vein distension, and there are no bruits. The lungs are clear heart sounds regular without murmurs, and abdomen is normal. The limbs are not well perfused distally. The neurologic examination reveals that he is alert and oriented, although he does not recognize he is sick. He shows loss of awareness and attention with respect to objects or stimuli on his left side. He has mild dysarthria but, his speech is fluent, and he understands and follows commands very well. There is mild weakness on the left side of the face and left sided homonymous hemaianopsia, but there is no nystagmus or ptosis, and no tongue or uvula deviation. He is not able to move his left arm and leg, has hyperreflexia, and the left great toe is upgoing.
What are two questions you would ask this patient?
Identify the subjective data for this patient.
Identify the objective data for this patient.
What is the likely diagnosis?
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
NU609 Advanced Health Assessment
Unit 13 Discussion
Pregnancy Exam
A 24-year-old patient who has never been pregnant before presents after having a positive home pregnancy test. She has no significant medical history. She denies symptoms and is worried because she has not felt the baby move thus far. Her last period was June 15 and today is August 20.
What are three questions you would ask this patient?
What would be her gestational age and expected due date?
How would you address her concern of not feeling the baby move?
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
NU609 Advanced Health Assessment
Unit 14 Discussion
Child Examination
You are seeing a 2 year old child with upper respiratory illness symptoms today in clinic. There are no signs of infection but the child’s mother is demanding an antibiotic for treatment.
How would you approach this situation?
What education can you give this parent?
Your response should include evidence of review of the course material, websites, and literature through proper citations using APA format.
NU609 Advanced Health Assessment
Unit 15 Discussion
Diabetes Treatment
You have a newly diagnosed diabetic 16-year-old female in your clinic.
Describe a teaching plan for this client.
How will your plan differ from an adult plan?
Give your rationale with documentation in APA format.
How will you incorporate the family in your plan, give rationale with documentation?
What other professionals will you include in the plan, give your rationale with documentation in APA format?
How will you address her participation on the basketball team at school, give rationale and documentation?
NU609 Advanced Health Assessment
Unit 16 Discussion
Reflection
Please respond to the following questions based upon these course objectives:
Synthesize broad ecological, global and social determinants of health; principlesof genetics and genomics; and epidemiologic data to design and deliver evidence based, culturally relevant clinical prevention interventions and strategies. AACN VIII.1
Evaluate the effectiveness of clinical prevention interventions that affect individual and population-based health outcomes using health information technology and data sources. AACN VIII.2
Design patient-centered and culturally responsive strategies in the delivery of clinical prevention and health promotion interventions and/or services to individuals, families, communities, and aggregates/clinical populations. AACN VIII.3.
Advance equitable and efficient prevention services, and promote effective population-based health policy through the application of nursing science and other scientific concepts. AACN VIII.4.
Integrate clinical prevention and population health concepts in the development of culturally relevant and linguistically appropriate health education, communication strategies, and interventions. AACN VIII. 5
Conduct a comprehensive and systematic assessment as a foundation for decision making. AACN IX. 1
Please answer the following questions with supporting examples and full explanations.
For each of the learning objectives, provide an analysis of how the course supported each objective.
Explain how the material learned in this course, based upon the objectives, will be applicable to professional application.
Provide evidence (citations and references) to support your statements and opinions. Responses to these questions are due by Tuesday at midnight.
NU609 Advanced Health Assessment
Unit 4 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your
note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection]
Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
3Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
NU609 Advanced Health Assessment
Unit 5 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection] Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
3Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
NU609 Advanced Health Assessment
Unit 6 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection] Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs. Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
NU609 Advanced Health Assessment
Unit 7 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection] Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
NU609 Advanced Health Assessment
Unit 8 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, and routes of administration. Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Health Maintenance/Promotion – Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
ROS: review of systems – [Refer to your course modules and the Bickley Etext (Bates Guide) as guide when conducting your ROS to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness.]
You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/categories applicable to your patient’s chief complaint.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection] Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.Plan (P):
NU609 Advanced Health Assessment
Unit 9 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection]
Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused)
visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allen compassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
NU609 Advanced Health Assessment
Unit 10 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection] Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
NU609 Advanced Health Assessment
Unit 11 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection] Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
NU609 Advanced Health Assessment
Unit 12 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection]
Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs. Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
NU609 Advanced Health Assessment
Unit 13 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection]
Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
NU609 Advanced Health Assessment
Unit 14 SOAP NOTE
SOAP Note Assignment Instructions
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection]
Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.3
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this
diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must
be found in the write-up.
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