USC Health & Medical A Male with Shortness of Breath Soap Nursing Assignment Help

Write a soap note using this information and the template below:

73 year old Hispanic male comes into the clinic with complaints of a cough that started 5 days ago, shortness of breath, chills and a temperature of 101.2. He has not taken any medications. 

Problem-Focused SOAP Note Format

Demographic Data

  • Age and gender (must be HIPAA compliant)

Subjective

  • Chief Complaint (CC): A short statement about why they are there
  • History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
  • Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
  • Family Hx: any history of CA, DM, HTN, MI, CVA?
  • Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
  • Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

  • Vital Signs
  • Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

Assessment (the diagnosis)

  • At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
  • Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

Plan

  • Dx Plan (lab, x-ray)
  • Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
  • Pt. Education, including specific medication teaching points
  • Referral/Follow-up
  • Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

Reference

  • Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly. 

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

i want you to complete this assignment Please read the Nursing Assignment Help

i want you to complete this assignment Please read the assignment carefully  here is the link of the assignment .. https://www.mediafire.com/file/4ucxvjjxbybplt7/PHA+outline+2024.docx/file https://www.mediafire.com/file/ofo0amjryc5zv63/PHA+questionnaire+2024.doc/file https://www.mediafire.com/file/h2ylykdgzccyb0c/action+plan+2024.doc/file

Trevino, A. J. (2021). Investigating Social Problems. Nursing Assignment Help

Trevino, A. J. (2021). Investigating Social Problems. Available from: VitalSourceBookshelf, (3rd Edition). SAGE Publications, Inc  This is the book Please respond to the following prompt. Grammar and spelling count. Draw upon the textbook and lecture notes in your response. What troubling social condition are you most concerned with (that may