Assignent Solutionnurs

T​‌‍‍‍‌‍‌‍‍‍‌‌‌‍‌‌‌‌‌‌​he SOAP note is for an episodic or sick visit for a patient with a complaint of abdomen pain to right lower quadrant. This note includes subjective (S) and objective (O) data, assessment (A), and a plan (P). Remember that the assessment (differential diagnoses) and plan must have 3 scholarly support from 2018-2022.
Chief Complaint: Abdominal Pain
Subjective (25 points)
Information about the patient (3 points)
• Name (initials only); age, and gender
CP, 8, Female
• Source of information; note relationship to patient, if relevant
Mother and patient, reliable
• Reliability of information
Chief Complaint (1 point)
History of Presenting Illness (8 points)
• Location
• Quality
• Quantity or severity
• Timing (onset, duration, frequency)
• Setting in which it occurs
• Factors that aggravate or relieve the symptoms
• Associated manifestations
Review of Focus System(s) (5 points)
Medications/Allergies (3 points​‌‍‍‍‌‍‌‍‍‍‌‌‌‍‌‌‌‌‌‌​)
History (5 points)
• Past Medical History
• Past Surgical History
• Family History
• Social History
• Health Maintenance Practices
• Objective (30 points)
Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems (20 points)
Appropriate techniques of examination used to identify pertinent findings (10 points)
• Assessment (20 points)
Differential diagnoses are supported by subjective and objective findings (15 points)
Scholarly resources support differential diagnoses (5 points)
Plan (15 points)
Comprehensive plan to address likely differential diagnosis includes (9 points)
• Diagnostic testing
• Pharmacologic intervention
• Non–pharmacologic intervention
• Referrals
• Patient education
• Follow–up
Plan is supported by appropriate and current practice guidelines (6 points)
Documentation (10 points)
Documentation follows SOAP temp​‌‍‍‍‌‍‌‍‍‍‌‌‌‍‌‌‌‌‌‌​late, is logical, and in correct format (10 points)