SOAP Note Assignmen

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SOAP Note Assignment

Click here
to download and analyze the case study for this week. Create a SOAP
note for disease prevention, health promotion, and acute care of the
patient in the clinical case. Your care plan should be based on current
evidence and nursing standards of care.

Visit the online library and research for current scholarly evidence
(no older than 5 years) to support your nursing actions. In addition,
consider visiting government sites such as the CDC, WHO, AHRQ, Healthy
People 2020. Provide a detailed scientific rationale justifying the
inclusion of this evidence in your plan.

Next determine the ICD-10 classification (diagnoses). The
International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-10-CM) is the official system used in the United
States to classify and assign codes to health conditions and related
information.

Click here to access the codes.

Download the SOAP template
to help you design a holistic patient care plan. Utilize the SOAP
guidelines to assist you in creating your SOAP note and building your
plan of care. You are expected to develop a comprehensive SOAP note
based on the given assessment, diagnosis, and advanced nursing
interventions. Reflect on what you have learned about care plans through
independent research and peer discussions and incorporate the knowledge
that you have gained into your patient’s care plan. If the information
is not in the provided scenario please consider it normal for SOAP note
purposes, if it is abnormal please utilize what you know about the
disease process and write what you would expect in the subjective and
objective areas of your note.

Format

  • Your care plan should be formatted as a Microsoft Word document.
    Follow the current APA edition style. Your paper should be no longer
    than 3-4 pages excluding the title and the references and in 12pt font.
  • Name your document: SU_NSG6001_W2A2_LastName_FirstInitial.doc.
  • Submit your document to the Submissions Area by the due date assigned.
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