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. OBSERVATION FOR IMPROVEMENT FROM THE PROFESSOR: Overall Feedback The ROS is subjective only. “Anxious look notes” is objective as an example. Your POC is directed strictly to the diagnosis and not the pt. What about referrals or other appointments, ect? Please remember that you must have a turn it in score of 25% or less on your week 4 SOAP note. I tried to explain and give grace to all students for week 2. In week 4 if you SOAP note TII score is high there will be more stringent penalties. I would suggest the following: 1. That you begin early in preparation for completion of the SOAP note. 2. If you do not understand TII scores you can reach out to the TII support by going to the policies and guidelines and you will find TII contact information there. 3. Look at all case study details to assure that you have a complete SOAP note. Adding in your own information from research that you have completed on the SOAP note will help decrease your TII score. https://www.cms.gov/medicare-coverage-database/search.aspx?error=Please%20use%20the%20new%20MCD%20Search%20to%20find%20documents%20with%20ICD-10%20codes. Dunphy, L., Winland-Brown, J., Porter, B. O., & Thomas, D. (2019). Primary Care: The Art and Science of Advanced Practice Nursing with Davis Edge (5th ed.). F.A. Davis. ISBN: 9780803667181. Fischbach, F., & Dunning, M., (2017). A Manual of Laboratory & Diagnostic Tests (10th ed.). Wolters Kluwer/Lippincott Williams & Wilkins. ISBN: 978-1496377128.
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