profjohnspense@gmail.com
+1 (941)-281-5715
LOGIN / REGISTER
MY ACCOUNT
Write Paper4u
  • Home
  • How it works
  • Service
  • About us
  • Contact us
ORDER NOW
Write Paper4u
  • Home
  • How it works
  • Service
  • About us
  • Contact us
ORDER NOW
MY ACCOUNT

ability to document a clinical encounter

This essay focuses ability to document a clinical encounter.. The SOAP note will be based on the given clinical case scenario detailed below.
Clinical Case Scenario
Dx: Bronchiolitis

 

ability to document a clinical encounter

With this assignment, you will demonstrate your ability to document a clinical encounter in the widely accepted SOAP note format. The SOAP note will be based on the given clinical case scenario detailed below.
Clinical Case Scenario
Dx: Bronchiolitis
A 12-month-old presents to your office in January with a 2-day history of runny nose and cough.

The child now has wheezing with nasal flaring and retractions, and his oxygen saturation is 89%. There has been no fever, and several of the other children and adults in the family have had “a cold” over the past several weeks. On examination, you hear scattered wheezes and rales. Allergies: NKDA
To complete this assignment successfully, you will need to read the assignment instructions and accurately address each criterion.
Assignment Instructions
Firstly, All SOAP note assignments will follow the format below. Your SOAP note must follow the APA format and should include a title page, in-text citations, and a reference page.
SUBJECTIVE
HPI

1.Firstly,    Document the information given in the case

2.Secondly,    Include a list of relevant questions you should ask in order to obtain any missing information
3.Thirdly,    Remember OLD CARTS when completing this task.
ROS
1.Firstly,    Document any symptoms given in the case
2. Secondly,   Include a list, per body systems, of ‘classic’ symptoms specific to the given diagnosis.
3.Lastly,    You may refer to your textbook or other resources to complete this section.
OBJECTIVE
VITAL SIGNS – Include a list of the following vital signs that correspond to the age of the presented patient – document what is given and assign a value to what is missing based on age. Height & Percentile; Weight & Percentile; Temperature; Blood Pressure; Heart Rate; and Respirations
PE

1.Firstly,    Document any exam findings given in the case

2.Secondly,    Include a list, per body systems, of the ‘classic’ physical examination findings specific to the given diagnosis.
3.Thirdly,    You may refer to your textbook or other resources to complete this section.
ASSESSMENT
Dx
1.   List the given diagnosis with the ICD-10 code. Include a brief description of the pathophysiology.
2.   List TWO differential diagnosis with their ICD-10 codes. Include a brief description of the pathophysiology and a rationale for the chosen differentials.

PLAN
Labs
1.Firstly,    Document any lab results presented in the case
2.Secondly,    List any tests you’d like to order – include the reason for the test and what it will show
Plan
1.Firstly,    Document the information given in the case
2. Secondly,   Document your treatment and management plan based a National Clinical Guidelines.
3.   You may NOT use your textbook for this; only clinical guidelines
Make sure to include:

Firstly,      Vaccines administered this visit
Secondly,       Medication-amounts and mg/kg for medications
Further,       Patient education about the condition including preventive care and anticipatory guidance
In addition,      Non-medication treatments
In addition,      Follow-up appointment with detailed plan of f/u
Finally, Reflection – Include your thoughts about the given case. What did you learn?

Why Choose US

Money Back Guarantee
Overnight delivery option
Experienced Experts
High Quality Work
24/7 support
Free revisions
Great discounts
Affordable prices
Paper Written from Scratch

Free Services

FREE Cover Page
FREE Reference page
FREE Table of Contents
FREE amendments and Revisions

Our services

Essay Writing
Term Papers
Dissertations writing
Research Papers
Assignments
Reports Writing
Thesis Writing
Editing
Resume Writing
GET A FREE QUOTE





  

Testimonials

I have had excellent experience with you! The writers which helped me in all my orders were excellent and they submitted before the deadline, even if the deadline was 24 hours or 7 days. Thank you a lot!

Client #50924
Business Management, 5 days ago

My experiences with cw.com has been great each time. I’m very honored to have such a team who care about the needs of their customers important matters. My work has never received a low grade only high ratings. Thank you

Client #5193
Philosophy, 3 Days ago

Thank you so much! This paper was written above reproach and I appreciate your dedication and attention to this project. Also, thank you for getting it to me early. This has been a major help! Ashley

Client #3214
Computer Science, 5 Days ago

We Accept

Services

  • Essay Typers
  • Write My Paper
  • Cheap Essay Writer
  • Essay Paper Writer
  • Write My Essay Paper
  • Dissertation Writers
  • Dissertation Writing Service
  • Freelance Essay Paper Writing
  • Research Paper Writing Service
  • Best Assignment Writing Help Service

Services

  • Case Study
  • Book Report
  • Master’s Essay
  • Term Paper
  • Shakespeare Essay
  • Application Paper
  • APA Style Papers
  • Essay Outline
  • University Essay
  • Custom Research Papers

Services

  • Dissertation/Thesis
  • Essay Outline
  • Essay Topics
  • Essay writers
  • Free Essays
  • Free Term Papers
  • Essay Topics
  • Essay writers
  • Extra services we offer:
  • Amazon listings

Services

  • Dissertation Writing Service
  • Do My Essay
  • Do My Essay For Me
  • Do My Paper
  • Doctoral Dissertation
  • Editing Writing
  • Essay Help
  • Product descriptions
  • Shopify listings
  • EBay listings

Quick Options

follow writepaper4u on Facebook

DMCA Protected - WritePaper4u.com
place an order now at writepaper4u
© 2020 writepaper4u.com. All Rights Reserved.