This assignment will demonstrate your ability to provide age-appropriate anticip

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.
PATIENT I EVALUATED IN UNIT 2 DETAILS:
NAME: ALEX ADAMS AGE: 38 YEARS
REASON FOR EXAM: CAME TO THE CLINIC FOR AN ANNUAL PHYSICAL EXAM
VITALS: PULSE: 75 SPO2: 98% BLOOD PRESSURE: 119/64 TEMPERATURE: 36.7 C
12 LEAD EKG: NORMAL SINUS RHYTHM
NO PAST MEDICAL HISTORY
NO FAMILY MEDICAL HISTORY
SEXUAL HISOTRY: LONG TERM RELATIONSHIPS, ALWAYS SAFE DURING ENCOUNTERS.
NO ALCOHOL / NO TOBACO/ NO DRUG USE
LIVING ARRANGEMNETS: LIVES ALONE
ALL OF HIS PHYSICAL EXAM WAS NORMAL FINDINGS IN A HEALTHY ADULT. NOTHING IS ABNORMAL.
ORDER DIAGNOSTICS:
COMPLETE BLOOD COUNT (CBC)
FOLLOW UP VISIT (12 MONTH)
HEALTH PROMOTION WELLNESS VISIT/ PHYSICAL EXAM
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. WILL ATTACH THE SOAP TEMPLATE BELOW.
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.