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.
Download the access 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.
Expert Solution Preview
In response to the given content, as a medical professor, I would like to emphasize the importance of creating a comprehensive SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. The SOAP note is a vital tool in the healthcare field as it allows healthcare professionals to organize and communicate patient information effectively.
To start, the SOAP note should include subjective information obtained from the patient, such as their chief complaint, medical history, and pertinent symptoms. This provides insight into the patient’s perspective and helps guide the care plan.
Next, the objective information should be documented. This includes physical assessments, vital signs, laboratory results, and any additional diagnostic information. It is important to include specific measurements and data to support the plan of care.
The assessment section of the SOAP note involves the healthcare professional’s clinical judgment based on the subjective and objective information. This is where the healthcare professional can diagnose the patient’s condition and identify any risk factors or areas for health promotion.
Finally, the plan of care should be developed based on current evidence and nursing standards of care. This may include interventions for disease prevention, health promotion, and acute care. It is essential to include specific rationales for each intervention, providing a scientific basis for the chosen actions. Research from reputable sources, such as the online library and government sites like the CDC, WHO, AHRQ, and Healthy People 2020, should be utilized to support the nursing actions in the plan of care.
In addition to the SOAP note, ICD-10 classification should be determined. This classification system is used to assign codes to health conditions and related information. It is crucial to accurately code the patient’s condition for proper documentation and communication between healthcare providers.
In summary, creating a comprehensive SOAP note based on the given clinical case requires incorporating subjective and objective information, making sound assessments, and developing a plan of care supported by current evidence and nursing standards. Proper utilization of the SOAP template and inclusion of detailed scientific rationale is essential to provide quality care to the patient.