SOAP Note Assignment
Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
Download the access codes.
Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.
- Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be no longer than 3-4 pages excluding the title and the references and in 12pt font.
- Name your document: SU_NSG6001_W4A2_LastName_FirstInitial.doc.
- Submit your document to the Submissions Area by the due date assigned.
Here is what my professor said about last paper
reviewed the submission on 4/16/19 did not identify which diagnosis applies to the patient,
what antibiotics would be ordered,
need to expand on health teaching
i lost 40 points….
Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of priority.)