NSG 6020 Soap Note – Hypothyroidism and Hyperglycemia

NSG 6020 Soap Note – Hypothyroidism and Hyperglycemia

NSG 6020 Soap Note – Hypothyroidism and Hyperglycemia

SOAP NOTE
Name:
J K
7/15/2016
Time: 9:00 am
Age: 43
Sex: Female

SUBJECTIVE
CC:
“I’m here to follow up after having an ear infection and to talk about my lab results and why I’m so tired
all the time”.

HPI:
Mrs. Keenan is 23 year old female patient presenting to the office today for a follow up after being treated with for an ear infection and complaints of constant fatigue. Her last visit consisted of an evaluation and lab work to determine the cause of fatigue. She denies any fever, shortness of breath or pain.

Medications:
Ciprodex 0.3-0.1% suspension. 4 gtts twice daily
Levothyroxine Sodium-250 mcg daily (ran out of medications 3 weeks ago)
Lasix-40 mg 1 tab daily
PMH

Allergies: NKA

Medication Intolerances: None listed

Chronic Illnesses/Major traumas

-Iron Deficiency Anemia (IDA)
-Hypothyroidism
-Hyperglycemia
-Vitamin D deficiency

Chronic Health Problems:
1. Iron Deficiency Anemia (IDA) (D50.9)
2. Hypothyroidism (E03.9)
3. Vitamin D Deficiency (E55.9)
4. Hyperglycemia (R73.9)

Hospitalizations/Surgeries
-Gallbladder surgery in 2003
-Breast biopsy in 2003

Other:
Immunizations:
Received flu vaccine in November 2015 and plans to receive it again when its time.
Environmental hazards:
Denies any environmental hazards. Lives at home with husband in a clean home.
Able to perform ADLs without difficulty.
Safety measures:
Stated “I always put my seatbelt on”.

NSG 6020 Soap Note – Hypothyroidism and Hyperglycemia

…

Kindly Order Now for a complete and more resourceful answer.

Rights of Medication Administration

Right time

• Check the frequency of the ordered medication.
• Double-check that you are giving the ordered dose at the correct time.
• Confirm when the last dose was given.

Right documentation

• Document administration AFTER giving the ordered medication.
• Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.

Right reason

• Confirm the rationale for the ordered medication.  What is the patient’s history?

NSG 6020 SOAP Note Assignments 

Week 5 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry. NSG 6020 Discussion Assignment Essay Papers

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 6 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 6 Physical Exam Video and Write Up Assignment

Complete Health History and Physical Assessment Write-Up Presentation

This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment.

Week 7 SOAP Note Assignment

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 8 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry. NSG 6020 Discussion Assignment Essay Papers .

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 9 SOAP Note Assignment

SOAP NOTE

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.