SOAP Note on a disease of the head, eyes, ears, nose, and throat system. Use the women’s health as an example. Use template to complete the SOAP Note on a disease of the head, eyes, ears, nose, and throat system

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An example of a SOAP note form can be found in thee-learn shell The SOAP documentation assignment Three Comprehensive SOAP Notes will be submitted over the course of the semester (one on a pediatric patient, one on a women’s health patient, and one on adult patients). If not comprehensive, you may be asked to submit another for grading. Objectives: 1. Demonstrate appropriate and effective oral and written communication with clients, their families, and other health professionals 2. Perform comprehensive and developmentally appropriate health assessments on children and adolescents 3. Develop management plans for health promotion, disease prevention, and acute and chronic illnesses in clients 4. Implement current research related to diagnostic and treatment protocols to improve the delivery of health care of clients Submit written documentation of a comprehensive patient encounter using the SOAP Documentation form. The documentation must include the following SOAP criteria. S = Subjective: Include the following: chief complaint, history of present illness (and history of any other current acute/ chronic illnesses being treated) medications, and allergies. Include past medical history, family history, social history, ROS, OB history (if applicable), last menstrual period (if applicable), and review of systems. (Include pertinent negatives as appropriate) Pediatric SOAP must include EPSTD and stages of development. 0 = Objective: Include vital signs, height, weight and other measurements as appropriate for age and condition, head to toe physical exam, and diagnostic findings including labs and procedures. A = Assessment: Include all differential diagnoses relevant to this visit along with the ICD-10 code, reasons for exclusion that culminate in a (some) final diagnosis with ICD-10 codes. P = Plan: Provide your complete plan of treatment including a list of all medications (dose, route,# refills), plans for additional diagnostic studies, and patient teaching, health promotion and health promotion activities, and your plans for a follow-up exam. Additionally, document all references and/or protocols used in APA format. These should be current within three years and are evidence-based. Protocols must be used and all references must have a citation within the SOAP. Every SOAP must be comprehensive and include all.

SOAP Note on a disease of the head, eyes, ears, nose, and throat system. Use the women’s health as an example. Use template to complete the SOAP Note on a disease of the head, eyes, ears, nose, and throat system