HEENT -SOAP NOTE

You will complete the learning module for Ear (capstone case study (ear) 85-year-old woman with hearing loss
1. You will access the assigned case study:
1. HEENT: Capstone Case Study the Capstone that is located in your Evolve Online BooK
2. Access the Evolve Chapter 13: Ears, Nose, and Throat, then self-paced learning modules, capstone case study Ear, Kathryn U, 85-year-old with hearing loss
2. You will complete the case study .you will obtain information from the scenario to complete the soap note

3. You will need to pose additional questions on your soap note, the scenario will supply some, but not all the history required. Utilize the Soap Note Form with the information that you obtained in completion of the assigned case study.
1. Think objectively, you will be given a diagnosis but is there another diagnosis or differential to consider and what information would be required to help you rule in/out a differential or to develop a plan of care
• Read the rest of the case study below and then complete the blank Soap Note attached to the scenario.
• Completion of your soap note will include Subjective AND Objective components as well as:
o · Medical Diagnosis (Formulate 2 (two) Primary Diagnoses)
 Decide what is pertinent and then place the components in the correct sections of subjective and objective components
 Use appropriate abbreviations and concise terminology if appropriate.
 If you are lacking pertinent information supply the questions that you would ask the patient (pretend you are completing the visit, how would you phrase the questions)
 Consider
 What type of history will you obtain for this visit? (The SOAP note Template is a Template used in multiple courses, some of the boxes may not be applicable to your assignment)
 What additional history would you obtain from the family that is significant to Kathryn’s situation?
 Practice using clinical reasoning and list possible diagnoses for Kathryn based on the subjective information provided
o The Following must be included in your SOAP submission:
 2 Primary Diagnosis
 ICD 10 code (you may do a simple google search)
 Provide pathophysiology for each diagnosis (1 paragraph)
 Pertinent positives for each diagnosis (list 2)
 Pertinent negatives for each diagnosis (list 2)
 3-5 Differential diagnosis
 ICD 10 code (you may do a simple google search)
 Provide pathophysiology for each diagnosis (1 paragraph)
 Pertinent positives for each diagnosis (list 2)
 Pertinent negatives for each diagnosis (list 2)
 Health maintenance/risk profile (if appropriate for your visit type)
 Reference List (you are researching your diagnosis you should have at least 2 references)
 APA format
There are 4 attachments below
o Capstone directions with screen shots (2).docx

o ROS Requirements (3).docx

o capstone rubric.pdf

o SOAPTemplate.docx

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