Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of
last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
General:
Head:
EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History.
Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

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Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P.
  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

Introduction

Many organizations work to better local and global communities' quality of life and promote health and safety in times of crisis. As public health and safety advocates, nurses must be cognizant of how such organizations help certain populations. As change agents, nurses must be aware of factors that impact the organization and the services that it offers. Familiarity with these organizations enables the nurse to offer assistance as a volunteer and source of referral.

This assessment provides an opportunity for you gain insight into the mission, vision, and operations of a community services organization.

Preparation

You are interested in expanding your role as a nurse and are considering working in an area where you can help to promote equal opportunity and improve the quality of life within the local or global community. You are aware of several nonprofit organizations and government agencies whose work contributes to this effort in some way. You have particular interest in one of these organizations but would like to know more about its contributions to public health and safety improvements. You would like to report the results of your research in a scholarly paper that you could submit for publication.

Research a local, national, or global nonprofit organization or government agency selected from the 
Assessment 02 Supplement: Community Resources [PDF] 
 Download Assessment 02 Supplement: Community Resources [PDF]resource. Determine how the selected organization or agency contributes to public health and safety improvements, promotes equal opportunity, and improves the quality of life within the community. Submit your findings in a 3–5 page report.

As you begin to prepare this assessment, it would be an excellent choice to complete the Nonprofit Organizations and Community Health activity. Complete this activity to gain insight into promoting equal opportunity and improving the quality of life in a community. The information gained from completing this activity will help you succeed with the assessment.

Note: As you revise your writing, check out the resources listed on the Writing Center's 
Writing Support page.

Instructions

First, select one of the local, national, or global nonprofit organizations or government agencies presented in the 
Assessment 02 Supplement: Community Resources [PDF] 
 Download Assessment 02 Supplement: Community Resources [PDF]resource.

Then research the nonprofit organization or government agency that you selected. Determine how the organization or agency contributes to public health and safety improvements, promotes equal opportunity, and improves the quality of life within the community. Submit your findings in a 3–5 page report structured according to the following specifications:

Document Format and Length

Format your paper using APA style.

· Refer to the 
APA Style Paper Tutorial [DOCX] to help you in writing and formatting your paper. Be sure to include:

· A title page and references page. An abstract is not required.

· Appropriate section headings.

· Your paper should comprise 3–5 pages of content plus title and references pages.

Supporting Evidence

Cite at least three credible sources from peer-reviewed journals or professional industry publications published within the past 5 years that support your research findings.

Graded Requirements

The research requirements, outlined below, correspond to the grading criteria in the assessment scoring guide, so be sure to address each point.

· Explain how the organization's mission and vision enable it to contribute to public health and safety improvements.

· Include examples of ways a local and/or global initiative supports organizational mission and vision and promotes public health and safety.

· Evaluate an organization's ability to promote equal opportunity and improve the quality of life in the community.

· Consider the effects of social, cultural, economic, and physical barriers.

· Assess the impact of funding sources, policy, and legislation on the organization's provision of services.

· Consider the potential implications of funding decisions, policy, and legislation for individuals, families, and aggregates within the community.

· Explain how an organization's work impacts the health and/or safety needs of a local community.

· Consider how nurses might become involved with the organization.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

· Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

· Write with a specific purpose and audience in mind.

· Adhere to scholarly and disciplinary writing standards and APA formatting requirements.

Additional Requirements

Before submitting your paper, proofread it to minimize errors that could distract readers and make it difficult for them to focus on your research findings.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Analyze health risks and health care needs among distinct populations.

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· Explain how an organization's work impacts the health and/or safety needs of a local community.

Competency 2: Propose health promotion strategies to improve the health of populations.

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· Explain how an organization's mission and vision enable it to contribute to public health and safety improvements.

Competency 3: valuate health policies, based on their ability to achieve desired outcomes.

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· Assess the impact of funding sources, policy, and legislation on an organization's service delivery.

Competency 4: Integrate principles of social justice in community health interventions.

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· Evaluate an organization's ability to promote equal opportunity and improve the quality of life in a community.

Competency 5: Apply professional, scholarly communication strategies to lead health promotion and improve population health.

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· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

· Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

Step 1 Post your response to the discussion board.

Currently, nursing services are considered an expense for which healthcare organizations cannot bill separately. Respond to the following questions and, if appropriate, include personal experience as part of your answers:

• Why are healthcare organizations unable to bill separately for nursing services, and what is the impact on nurse leaders?
• What can the nursing profession, and specifically nursing leaders, do to change this issue?
• Why are nursing services considered an expense and not an income generator?

Step 2 Read other students’ posts and respond to at least two of them by Friday at 11:59pm Mountain Time.

Ask questions of the other students that promote further thinking and discussion on the topic. Consider the changes to billing identified by the other students. Do you agree or disagree that these changes can make an impact on nursing services? Why or why not?

Use your personal experience, if it’s relevant, to support or debate other students’ posts. If differences of opinion occur, debate the issues professionally and provide examples to support opinions.

I attached assignment task description 

 Hello, this work is on Advanced Pathophysiology, it must have a minimum of 300 words and a bibliographic reference. The bibliography used on the topic is McCance, K. L. & Huether, S. E. (2019). Pathophysiology: the biological basis of diseases in adults and children. But you can use another one in addition to this one.  

 When highly acidic chyme enters the duodenum, which hormone stimulates the release of pancreatic secretions that contains very high bicarbonate ion content? Explain your answer.

a. Gastrin
b. Secretin
c. Cholecystokinin

d. Histamine