NSG 6435 Pediatric SOAP Note

THIS IS A FIVE YEAR OLD WELL CHILD CHECK COMPLAINING OF A GASTROENTERITIS. WOULD YOU DO ANY LABS? WHAT BRINGS YOU TO PRIMARY DIAGNOSIS MUST HAVE SUPPORTING DOCUMENTATION FOR PRIMARY DIAGNOSIS. ALSO GIVE 3 DIFFERENT DIFFERENTIAL DIAGNOSIS AND EXPLAIN WHY THESE WOULD NOT BE IT. MUST GIVE SUPPORTIVE DOCUMENTATION. PLEASE INCLUDE ASQ SCORES AND MANDATORY TO LIST ALL VACCINATIONS HAVE HAD DONE UP TO THIS VISIT AND WHAT IS NEEDED AT THE VISIT. PLEASE MAKE SURE TO INCLUDE REVIEW OF SYSTEMS. I AM JUST TRYING TO REMEMBER WHAT ALL I HAVE BEEN COUNTED DOWN WITH PRIOR SOAP NOTES.

Your Well Child Note. Take some time to review the provided example. Select a patient who you examined during the last 4 weeks. With this patient in mind, address the following in a SOAP Note:
•Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.  NSG 6435 Pediatric SOAP Note.
•Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
•Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
•Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
•Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

The SOAP note is one of the most popular methods for documenting care delivery. However, completing a focused SOAP note requires a lot of research and critical analysis in comparison to the standard essay. Many nursing students do not know where to start when writing an episodic/focused SOAP note. Having to write several SOAP note reports concurrently complicates things. I remember the first time my professor ordered us to complete an episodic/focused SOAP note. Although I was familiar with the term, I had never concerned myself with this documentation methodology. I quickly emailed the professor and requested for several SOAP note examples/samples that could guide me in completing the assignment. However, I realized that there was not enough time to familiarize myself with the episodic/focused SOAP notes writing and format and complete the assignment. Quickly, I searched for SOAP note writing services online and ordered a custom SOAP note paper from mynursingwritingservices.com. The assigned writer completed the SOAP note quickly. I gained several crucial insights by reading the focused SOAP note sample provided by the nursing writing service. To date, mynursingwritingservices.com has helped me to complete several SOAP note reports covering various diseases including pneumonia, hypertension, asthma, diabetes and abdominal pain.

Episodic focused soap note format

The SOAP note format has some similarities with the history and physical (H&P) report. However, it differs completely with the format for the standard essay. A focused SOAP note contains for key headings. These are the subjective, objective, assessment and plan. Ensure that you understand fully the focused SOAP note format before starting to write your paper. The subjective heading contains information relating to the feelings, experiences, views and lifestyle of the patient. The patient is the main source of the subjective data. However, the clinician may engage the patient’s family members to have a better understanding of the presenting condition. When writing your SOAP note paper ensure that the subjective section contains the chief complaint, history of present illness, medical history, family history, social history and review of systems (ROS). This information is crucial in determining the potential cause of the chief complaint. The other important component of the focused SOAP note format is the objective data. This section contains information such as the vital signs, physical exam, lab and diagnostic data. The clinician uses both the subjective and objective data to diagnose the patient and develop a suitable treatment plan. Finally, the assessment and plan sections of the SOAP note contain the differential diagnosis and treatment plus patient education respectively. Often, the assessment involves differential diagnosis with the clinician considering multiple possible conditions and determining the primary diagnosis. You can download focused SOAP note examples and templates online from websites such as mynursingwritingservices.com. NSG 6435 Pediatric SOAP Note.

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Focused soap note for diarrhea/knee pain/sore throat/sinusitis

You must complete several SOAP note reports before graduating. Some of the focused SOAP note assignments you should expect to complete include SOAP note for asthma, diabetes, hypertension, diarrhea, knee pain, sore throat and SOAP note for sinusitis. Writing focused SOAP note reports on the common clinical conditions is an excellent way for nurses to enhance their care delivery. For example, writing a SOAP note on diarrhea exposes the health care provider to the different food and water-borne pathogens and appropriate intervention for the infected persons. Recently, I complete a focused SOAP note for a patient with wrist pain and tingling, numbness and weakness in the fingers. The SOAP note exposed me to various musculoskeletal and neurological disorders and cancers. Similarly, the focused SOAP note for sinusitis thrust me into the complexities of HEENT assessment and the diverse HEENT complications, especially affecting the pediatric population. Always remember that the SOAP note format does not change regardless of the clinical condition. Having a standard SOAP note format allows easy management of the patient by different healthcare providers because they can access and interpret the patient’s medical records without any confusion.

Download file to see previous pages The patient further complains of general weakness of the whole body, painful aches all over his body, and itchy eyes, together with a running nose, sore and dry throat. He further complains of coughing. The patient subsequently denies that he has any form of nausea and vomiting. The history of the male patient is that he has been experiencing severe cold and nose blockage since birth. This shows that the patient has been having this problem ever since he was young. Further evidence shows that he has been under medication for the past years. He further claims that the drugs that he is been administered has been giving him difficulties during feeding and moreover during sleep. The patient further has a history of diabetes which he inherited from his parents. This diabetes has led to the lowering of his immune system response and the slow healing of wounds. This is manifested by the presence of the non – healing wounds on his right leg. ROS: Diabetes.  NSG 6435 Pediatric SOAP Note.Head: The patient claims of severe and recurring headaches. ENT: The patient complains of severe pain and discomfort during eating and also when talking on his throat. Eyes: The patient experiences sore and itchy eyes. He further experiences blurred vision due to the presence of tears on his eyes. Cardio: The patient complains of pain in the chest while breathing and coughing. …
The patient complains of a recurring and severe headache and sore throat. Allergies: The patient is not experiencing any form of allergy towards dust, cold, or drugs. Medications: The patient is under the medication of diabetes that he inherited from his parents. -Acetaminophen drug -Tylenol -Ibuprofen (Advil and Motrin) -Cough syrup -Other diabetes drugs PMH: -Diabetes -Wounds that take time to heal -Severe fever -Chills Past surgical hx: The patient has never undergone any form of surgical operations. Family hx: The patient has diabetes that he inherited from his parents. Social hx: The patient is married. Have three children; one son and two daughters. He denies that he uses drugs, but he smokes and also drinks alcohol. Objectives: Vitals: HR: 71, BP: 118/71, RR: 21, T: 103.0 oral Physical exam: The patient has a blood group of O+ (positive). He has unclear speech, and uses a lot of energy to walk. Cardio: The patient has a regular rhythm and rate. Resp: The bilateral breath of the patient is not very clear because of sore throat and nose blockage. Thus, he is having difficulty in breathing. Skin: Dry, warm, the nose and the cheeks are pink in color. The patient also has flushed skin. Abd: Soft and non – distended. Lymph: There is presence of palpated lymph nodes under the armpits and other locations of the body. Stool for OC: Negative Labs (1/4/12) – pre transfusion: HGB: 7.9, HCT: 25.6, WBC: 12, PLT: 469, RBC: 2.21, MCV: 87, ALBUMIN: 2.0, PRE – ALBUMIN: 20.1, GLOBULIN: 5.0, IRON: 27 Labs (1/10/12) – post transfusion: HGB: 10.6, HCT: 30.9, WBC: 10, PLT: 430, RBC: 4.21, MCV: 84, RDW: 15.3, RETIC COUNT: 1.7, BUN: 29, CR: 1.12, GFR: 43. 2D Cardiac Echo (10/09/11) EF: 50 – 60% MVP ENT …

NSG 6435 Pediatric SOAP Note