Soap Note 2 Adult Wellness Check Up /Annual Physical Paper

/in /by

Soap Note 2 Adult Wellness Check Up /Annual Physical Paper

Note: Wellness check up or Annual physical exam can only have two possible diagnoses. ICD 10: Z00.00 or Z00.01. Any other abnormal finding should be placed in the differential diagnosis and clearly supported in your progress note under assessment.

Please keep this in mind. No other possible diagnosis for this encounter is accepted for any insurance. You must include all the USPSTF recommendation according to your patient age and sex under Planning.

This soap needs to be done for a patient between the ages of 23 to 69.  Please see the video (https://youtu.be/NYqB-2frWfc) provided in the previous assignment BEFORE starting your SOAP note.

ORDER NOW FOR CUSTOMIZED SOLUTION PAPERS

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 25% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated. Soap Note 2 Adult Wellness Check Up /Annual Physical Paper

Soap Note 2 Adult Wellness Check Up /Annual Physical Paper

Please see College Handbook with reference to Academic Misconduct Statement.

 

The use of Templates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made-up patient.

NOTES:

  1. We need to choose a patientAGE clinic history for Adult Wellness Check Up /Annual physical them: You must include all the USPSTF recommendation according to your patient age and sex under Planning.
  2. Use a template attached, own words No plagiarism, references APA 7th edition

 (Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

 

Soap Note # ____   Main Diagnosis ______________

 

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

Soap Note 2 Adult Wellness Check Up /Annual Physical Paper

Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …

 

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

 

Objective Data:

VITAL SIGNS:

 

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

 

ASSESSMENT:

(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)

Example : “Pt came in to our clinic c/o of earpain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3)

–

-Soap Note 2 Adult Wellness Check Up /Annual Physical Paper

–

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

  • –
  • –

Pharmacological treatment:

–

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

 

Follow-ups/Referrals

References(in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series). Soap Note 2 Adult Wellness Check Up /Annual Physical Paper