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
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
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.
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.
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.
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.
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
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.
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.
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
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?