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Unit 3 Plan of Care for Ear Pain

Create a Plan of Care for the assigned Ear Pain Case. Address the subjective and objective data by creating an assessment and plan of care for the patient. Please use the Template provided for you.

SOAP/Case Study NOTE TEMPLATE

Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis.

Subjective Data

Chief Complain (CC):

History of Present Illness (HPI):

Last Menstrual Period (LMP- if applicable)

Allergies:

Past Medical History:

Family History:

Surgery History:

Social History (alcohol, drug or tobacco use):

Current medications:

Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI). Only review the systems that are relevant to the chief complaint and HPI

Objective Data

Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess pertinent systems.

Vital Signs/ Height/Weight:

General Appearance:

HEART:

RESP:

Assessment

A: Differential Diagnosis Please rule out all differential diagnosis with subjective and objective data and/or lab-work.  

1.

2.

3.

B: Medical Diagnosis Please provide rationale Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis.

 

1.

PLAN

A: Orders

1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided. (If the patient is currently on a medication please list them and include the same information)

2. Mechanisms of action for each medication prescribed and current medications.

a. For all medications please include the above in addition to the Mechanisms of action, patient teaching

3. Diagnostic testing

4. Problem oriented education

5. Ethical and cultural consideration

6. Health Promotion/Maintenance Needs

7. Developmental stage

8. Referrals

B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)