SOAP Note Assignment

Running head: NAME OF CARE PLAN

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Title of Plan of Care Name South University Online Faculty Name NSG 6001 Date

NAME PLAN OF CARE 2

**Please delete this statement and anything in italics prior to submission to shorten the length of your paper.

Patient Initials ______ Subjective Data: (Information the patient tells you regarding themselves: Biased Information):

Chief Compliant: (In patient’s exact words)

History of Present Illness: (Analysis of current problems in chronologic order using symptom analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated symptoms and treatments tried]).

PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history, obstetric and history sexual history).

Significant Family History: (Includes family members and specific inheritable diseases).

Social History: (Includes home living situation, marital history, cultural background, health habits, lifestyle/recreation, religious practices, educational background, occupational history, financial security and family history of violence).

Review of Symptoms: (Review each body system - This section you should place POSITIVE for... information in the beginning then state Denies...). - General:; Integumentary:; Head:; Eyes: ; ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:; Neurological:; Endocrine:; Hematologic:; Psychologic: .

Objective Data: Vital Signs: BP - ; P ; R ; T ; Wt. ; Ht. ; BMI . Physical Assessment Findings: (Includes full head to toe review) HEENT: Lymph Nodes: Carotids: Lungs: Heart: Abdomen: Genital/Pelvic: Rectum: Extremities/Pulses: Neurologic: Laboratory and Diagnostic Test Results: (Include result and interpretation.)

Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of priority.)

Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided).

NAME PLAN OF CARE

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References