NSG 6020 Soap Note – GENOGRAM & SOAP

NSG 6020 Soap Note – GENOGRAM & SOAP

NSG 6020 Soap Note – GENOGRAM & SOAP SAMPLE SOLUTION

Subjective data: CJ is a 34-year-old African American male with an unremarkable past medical history. He is a military member who completes a yearly health assessment and exercises 5 times a week. CJ appears to be well nourished in no acute distress.

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Chief complaint: CJ has no complaints at this time.

Past medical history: as previously mentioned CJ has an unremarkable past medical history, with no complaints at this time.

Social history: CJ does not drink or smoke. CJ has been married 10 years and has three children.

Family history: Father has hypertension, diabetes type 2, and obesity. Mother has hypertension and obesity. Maternal grandmother has passed away from heart disease. Maternal grandfather still living with controlled essential hypertension. Paternal grandmother deceased, history of hypertension and diabetes type 2. Paternal grandfather also deceased with no pertinent history.

Medications: CJ takes a daily multivitamin.

Objective data:

Vital signs: temperature 98.7, pulse 72, respirations 18, blood pressure 110/70, weight 185, height 6’1”, BMI 24.4.

NSG 6020 Soap Note – GENOGRAM & SOAP

Physical examination: CJ is alert and oriented in no acute distress.

General: Well appearing, well nourished, in no distress.

Oriented x 3, normal mood and affect. Ambulating without difficulty.

Skin: Good turgor, no rash, unusual bruising or prominent lesions.

Hair: Normal texture and distribution.

Nails: Normal color, no deformities

HEENT: Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.

Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages

Ears: EACs clear, TMs translucent & mobile, and hearing intact.

Nose: No external lesions, mucosa non-inflamed, septum normal

Mouth: Mucous membranes moist, no mucosal lesions.

Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant resorption.

Pharynx: Mucosa non-inflamed

Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender

Heart: regular rate and rhythm, no murmur or gallop heard on auscultation

Lungs: Clear to auscultation and percussion. NSG 6020 Soap Note – GENOGRAM & SOAP

Assessment:

Z00.00 encounter for general adult medical exam without abnormal findings.

Z68.24 BMI 24.0 – 24.9

Plan:

NSG 6020 Week 6 Discussion

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to the given question in the Discussion Area by the due date assigned.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week. NSG 6020 Soap Note – GENOGRAM & SOAP.

Assignment

Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Miah Zavarro V3

Click here for information on how to access and navigate iHuman.

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client. NSG 6020 Course Discussion Assignment Papers.

Week 7 Discussion

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to the given question in the Discussion Area by the due date assigned.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

Assignment

Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Carolyn Cross V2 VE

Click here for information on how to access and navigate iHuman.

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.

Week 8 Discussion

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to the given question in the Discussion Area by the due date assigned.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

Assignment

Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Christine Smith V3

Click here for information on how to access and navigate iHuman.

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client. NSG 6020 Soap Note – GENOGRAM & SOAP.

Week 9 Discussion

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to the given question in the Discussion Area by the due date assigned.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

Assignment

Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Gloria Jenkins V3 PC

Click here for information on how to access and navigate iHuman. NSG 6020 Course Discussion Assignment Papers.

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client. NSG 6020 Soap Note – GENOGRAM & SOAP.

Week 10 Discussion

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to the given question in the Discussion Area by the due date assigned.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

Assignment

Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Bebe Babbitt V4 PC

Click here for information on how to access and navigate iHuman. NSG 6020 Course Discussion Assignment Papers.

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client. NSG 6020 Soap Note – GENOGRAM & SOAP.

Week 5 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 6 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned. NSG 6020 Course Discussion Assignment Papers.

Week 6 Physical Exam Video and Write Up Assignment

Complete Health History and Physical Assessment Write-Up Presentation

This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment.

Week 7 SOAP Note Assignment

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned. NSG 6020 Soap Note – GENOGRAM & SOAP.

Week 8 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided

Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 9 SOAP Note Assignment

SOAP NOTE

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided. NSG 6020 Course Discussion Assignment Papers.

Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

 

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