Heent soap note - Study guides, Class notes & Summaries

·Communication techniques used to obtain a patient's health history Courtesy, Comfort, Connection, Confirmation Courtesy Communication Technique • Knock before entering a room. • Address, first, the patient formally (e.g., Miss, Ms., Mrs., Mr.) It is all right to shake hands. • Meet and acknowledge others in the room and establish their roles and degree of participation. • Learn their names. • Ensure confidentiality. • Be in the room, sitting, with no effort to reach too so...

NRNP 6540 Week 10 Focus SOAP Note- Musculoskeletal/Neurological Jamie Boggs NRNP 6540 Dr. Petko Walden University May 10, 2021 Week 10 Focused SOAP Note- Musculoskeletal/Neurological Patient Information: M.L., 66 y.o., Male, Hispanic S (subjective) CC (chief complaint): Acute aphasia, right facial droop, and right-sided weakness. HPI (history of present illness): M.L., is a 66 y.o., Hispanic, male who presents to the ED after EMS was called by a co-worker for acute...

Module 1 - Health History Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Timeframe: 1 week after fall (Age: 28) Reason for visit: Patient presents for an initial primary care visit today complaining of an infected fo...

MSN 572 HEENT Soap Note

NRNP 6540 Week 4 Assignment Week 4: Case Study 1: A 76-year-old woman presents today with complaints of nasal drainage Head, Neck, and Face Disorders in the Older Population NRNP 6540F Advanced Practice Care of Older Adults Head, Neck, and Face Disorders in the Older Population Older adults face many age-related disorders that involve the head, neck, ad face. Advanced practice nurses should assess older patients appropriately, as many of these conditions significantly affect their qualit...

NRNP 6540 Week 10 Focus SOAP Note- Musculoskeletal/Neurological Jamie Boggs NRNP 6540 Dr. Petko Walden University May 10, 2021 Week 10 Focused SOAP Note- Musculoskeletal/Neurological Patient Information: M.L., 66 y.o., Male, Hispanic S (subjective) CC (chief complaint): Acute aphasia, right facial droop, and right-sided weakness. HPI (history of present illness): M.L., is a 66 y.o., Hispanic, male who presents to the ED after EMS was called by a co-worker for acute...

NR 602 WK 5SOAP NOTE FORMAT - JO NR 602 WK 5 SOAP Note Format - Jo Patient Information: J.F., 6y/o Caucasian girl S. CC (chief complaint) – “Vomiting, diarrhea and fever” HPI: 6 old girl p/w vomiting x2 days/diarrhea x1 day/fever 100-101degrees/severe lower abd pain x1 day. Last meal was at a pizza buffet 36hrs ago, otherwise no solid foods since then, consumed sprite, apple juice and popsicles instead. Administered Pepto-Bismol (OTC) & Tylenol x2-3/day for fever. There ar...

(SOAP NOTE) NR511 WEEK 4 M. MILLER Patrick Smith 42 YO(CC Pain in back and abdomen)M. Miller SOAP WEEK 4 Patrick Smith Age 42 Subjective Chief complaint: “I am in a lot of pain in my back and abdomen” History of present illness (HPI): O: Onset- 5 am L: Location—initially pain begin on the side of his back; and now there is also pain in his stomach D: Duration-intermittent pain that comes in waves C: Characteristics/Associated symptoms- throbbing, feels nauseated, urinary frequency, sweaty,...

Diagnostic Reasoning Case Study Jennifer Hood University of Texas Arlington College of Nursing and Health Innovation Nursing 5333 Family Nursing I Kashiris Perryman, DNP, APRN, FNP-PC June 12, 2021 Soap Note S/ Identifying Information: Martha 26 yo female DOB July 12, 1995 Family Hx: Mother--DM (Alive) Father—COPD (Alive) Brother—No preexisting conditions (Living) Personal/Social Hx: Chief Complaint/RFE: College Graduate Currently employed as a schoolteacher Fin...

SOAP Note on Harvey Hoya Patient Initials: HH Age: _57 Gender:_M_ SUBJECTIVE DATA: Chief Complaint (CC): “I can’t stop snoring when sleeping and I don’t have adequate sleep” History of Present Illness (HPI): the client, HH is a 57-year-old male Hispanic who presented with complaints of challenges sleeping and constantly snoring while asleep. The client is a construction worker and also presented with elevated blood pressure while also indicating that he h...