This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on the virtual reality patient you evaluated in Unit 2.
Write-ups
The SOAP note serves several purposes:
It is an important reference document that provides concise information about a patient’s history and exam findings at the time of patient visit.
It outlines a plan for addressing the issues which prompted the office visit. This information should be presented in a logical fashion that prominently features all of the data that’s immediately relevant to the patient’s condition.
It is a means of communicating information to all providers who are involved in the care of a particular patient.
It allows the NP student an opportunity to demonstrate their ability to accumulate historical and examination-based information, make use of their medical knowledge, and derive a logical plan of care.
Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the H&Ps that you create as well as by reading those written by more experienced practitioners.
The core aspects of the SOAP note are described in detail below.
For ease of learning, a SOAP Note Template has been provided. For this assignment, proper citation and referencing is required because this is an academic paper.
S: Subjective information. Everything the patient tells you. This includes several areas including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.
O: Objective is what you see, hear, feel or smell. Your physical exam includes vital signs.
A: Assessment/Your differentials
P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.
If there are any questions, please contact your instructor.
BELOW I HAVE ATTACHED THE COMPLETED SOAP PAPER FOR THIS PATIENT. ALL I NEED ASSISATNCE WITH IS ADDING REFERENCES TO SOME ANTICIPATORY GUIDANCE. THIS IS WHAT THE PROFESSOR STATED ON THE SEMINAR.
So the journal. People sometimes are confused by this, and they say, Well, you know, the soap note is is the same as my from the virtual reality is same as the soap note for the journal and and it it is very similar. But in this week’s journal activity, which is soap, note the focus on this one is more strongly on anticipatory guidance for this patient.
And this is the journal where you
reference.
whatever anticipatory guidance you’re going to be doing with some national guidelines. And so what this kind of forces you to do?
is this pediat? This patient’s not a pediatric. But let’s just say for a moment. It’s a pediatric patient, and the anticipatory guidance for this particular patient is car seats.
You would look up some guidelines on car seats
and reference them. That’s that’s kind of a broad example. But that’s the point of this week is to kind of get ourselves to thinking about the whole person.
not just the history, not just the physical, but going forward. The whole person
so anticipatory guidance is very important. This guy’s got quite a bit you can do, and the anticipatory guidance in this journal should only be for this patient. And as we go forward with all of these case studies, this is very critical piece of information you are treating the patient in front of you, not the age group. That’s epidemiology, not the gender.
not
patients at this age. Should this patient. What about this patient
and what this does? It’s beginning to help you to mimic
the
That’s the word. I want to mimic the the office setting the primary care setting. So you start to feel like, okay, so I’m in the setting. And I’m obsessing this patient. And my assessment. He needs this, or she needs that. Okay, so that’s the point of the journal this week to put you into the anticipatory guidance mode.
SO PLEASE AT LEAST 3 REFERENCES TO SOME ANTICIPATORY GUIDANCE FOR THIS PATIENT.
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