Review the Subjective and Objective elements of the attached document to determine the appropriate diagnoses to assign (‘A’) and construct an Evidence-based ‘Plan”.
Use your ‘model’ thinking as you assign the diagnoses including in parentheses behind each diagnosis the pertinent positives and pertinent negatives that you are using to support the diagnoses you assigned
Elements of the ‘plan’ need to reflect current EBP and CPGs. Be sure to include appropriately constructed in-text citations.
Utilize to the information below that is copied-and-pasted out of the SOAP Note Assignment instructions to assist you in formatting your post:
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication}.
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed}. Pertinent positives and negatives must be found in the write-up.
Plan (P):
These are the interventions that relate to each individual, numbered diagnosis.
Document individual plans directly after each corresponding assessment (Ex. Assessment Plan). Address the following aspects (they should be separated out as listed below):
Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint
Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications.
Educational: information clients need in order to address their health problems. Include follow up care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.
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