Heent soap note - Study guides, Class notes & Summaries

EYoung Cardiovascular SOAP Note Harvey Hoya Graded A+ SOap Note Blue Print Course: NURS5102R50 Student: Emily Young Faculty: Dr. Tracy Collins Pt Initials: HH Age: 57 Race: Hispanic Sex: M New Pt: Y Established Pt: Info Source: Patient Reliability: Reliable E&M Code(s) I.10 S CC: Elevated blood pressure HPI: A 57-year-old Hispanic male presents to the clinic “I had my blood pressure checked at a health fair earlier and it was high, my wife convinced me to come in.” Patient describes a...

Erin Bradley i-Human Case Study CC: Nausea and Vomiting SOAP Note #3 2023 All the Sections Latest Updates question and Answers. SOAP Note #3 3/23/2021 Chief complaint: Nausea and vomiting, feeling shaky and hot along with a flutter in chest 1. Identifying data: Name: Erin Bradley Age: 21 Sex: Female Source: Patient who is a reliable historian. 2. HPI: Ms. Bradley is a 21 years old college student who appears to be moderately distress with complaints of worsening weakness, nausea...

Diagnostic Reasoning Case Study Jennifer Hood University of Texas Arlington College of Nursing and Health Innovation Nursing 5333 Family Nursing I Kashiris Perryman, DNP, APRN, FNP-PC June 12, 2021 Soap Note S/ Identifying Information: Martha 26 yo female DOB July 12, 1995 Family Hx: Mother--DM (Alive) Father—COPD (Alive) Brother—No preexisting conditions (Living) Personal/Social Hx: Chief Complaint/RFE: College Graduate Currently employed as a schoolteacher Fin...

C (abd soft and nontender is an objective assessment finding) - Of the following, which is NOT considered subjective information? A. Ear pain for 5 days B. No cough noted C. Abdomen soft, nontender D. "I have a headache" A (how many times) - You are gathering information from a patient for the HPI portion of your SOAP note. Of the following information, what else might you include in this section? a. How many times the patient has experienced the symptom in the past b. The medication ...

Module 1 - Health History Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Timeframe: 1 week after fall (Age: 28) Reason for visit: Patient presents for an initial primary care visit today complaining of an infected fo...

MSN 572 HEENT Soap Note

Erin Bradley i-Human Case Study CC: Nausea and Vomiting SOAP Note #3 2023 All the Sections Latest Updates question and Answers. SOAP Note #3 3/23/2021 Chief complaint: Nausea and vomiting, feeling shaky and hot along with a flutter in chest 1. Identifying data: Name: Erin Bradley Age: 21 Sex: Female Source: Patient who is a reliable historian. 2. HPI: Ms. Bradley is a 21 years old college student who appears to be moderately distress with complaints of worsening weakness, nausea...

NRNP 6540 Week 10 Focus SOAP Note- Musculoskeletal/Neurological Jamie Boggs NRNP 6540 Dr. Petko Walden University May 10, 2021 Week 10 Focused SOAP Note- Musculoskeletal/Neurological Patient Information: M.L., 66 y.o., Male, Hispanic S (subjective) CC (chief complaint): Acute aphasia, right facial droop, and right-sided weakness. HPI (history of present illness): M.L., is a 66 y.o., Hispanic, male who presents to the ED after EMS was called by a co-worker for acute...

Define diagnostic reasoning - Reflective thinking because the process involves questioning one's thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. Seen as a kind of critical thinking. What is subjective data? - What the patient tells you, complains of, etc. Chief complaint HPI ROS What is objective data? - What YOU can see, hear, or feel as part of your exam. Includes lab data, diagnostic test results. Com...

·Communication techniques used to obtain a patient's health history Courtesy, Comfort, Connection, Confirmation Courtesy Communication Technique • Knock before entering a room. • Address, first, the patient formally (e.g., Miss, Ms., Mrs., Mr.) It is all right to shake hands. • Meet and acknowledge others in the room and establish their roles and degree of participation. • Learn their names. • Ensure confidentiality. • Be in the room, sitting, with no effort to reach too so...