NR 509 Discussions SOAP Note and Reflection Chamberlain
NR 509 Discussions SOAP Note and Reflection Chamberlain
NR 509 Week 1 Discussion (Patient Information: JDS, 30, M, African American, Cigna)
NR.509 Week 2 Discussion (Patient Information: KMW, 27, F, African American, Aetna)
NR 509 Week 3 Discussion (Patient Information: SJS 33, F, African American, Cigna)
Using a friend, family member, or colleague, perform a neurovascular (include all cranial nerves), musculoskeletal, and cardiopulmonary (includes the heart, lungs, and peripheral vasculature) exam. Document the physical examination findings in the SOAP note format.
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Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included………… plan portion of the SOAP note, but these sections will not be graded.
You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of headache, back pain, and cough. ______ ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend.
* There are videos of the exams to be performed at immersion in Modules → Introduction and Resources→ Immersion section. Also the immersion evaluation forms are located in the Course Resources section. They should be reviewed and practiced often.
NR.509 Week 4 Discussion (Patient Information: NJL, 22, M, African American, Cigna)
Using a friend, family member, or colleague, perform a detailed men’s health history. Document the history and the expected normal physical examination findings in the SOAP note format.
Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included…………..assessment and plan portion of the SOAP note, but these sections will not be graded.
You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of penile discharge, rectal bleeding, or frequent urination. You should also focus the ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend.
* There are videos of the exams to be performed at immersion in Modules → Introduction and Resources→ Immersion section. Also the immersion evaluation forms are located in the Course Resources section. They should be reviewed and practiced often.
NR 509 Week 5 Discussion (Patient Information: JDS, 21, M, African American, Blue Cross Blue Shield)
Using a friend, family member, or colleague, perform a detailed women’s health history. Document the history and the expected normal physical examination findings in the SOAP note format.
Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included. You may include the assessment and plan portion of the SOAP note, but these sections will not be graded.
You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of burning while urinating, irregular menstrual cycle, or pelvic pain………. focus the ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend.
* There are videos of the exams to be performed at immersion in Modules → Introduction and Resources→ Immersion section. Also the immersion evaluation forms are located in the Course Resources section. They should be reviewed and practiced often.
