SOAP Note Assignment Discussion Paper

Click  here  to download and analyze the case study for this week. Create a SOAP  note for disease prevention, health promotion, and acute care of the  patient in the clinical case. Your care plan should be based on current  evidence and nursing standards of care.

Visit the online library and research for current scholarly evidence  (no older than 5 years) to support your nursing actions. In addition,  consider visiting government sites such as the CDC, WHO, AHRQ, Healthy  People 2020. Provide a detailed scientific rationale justifying the  inclusion of this evidence in your plan SOAP Note Assignment Discussion Paper.

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Next determine the ICD-10 classification (diagnoses). The  International Classification of Diseases, Ninth Revision, Clinical  Modification (ICD-10-CM) is the official system used in the United  States to classify and assign codes to health conditions and related  information.

Click here to access the codes.

Download the SOAP template  to help you design a holistic patient care plan. Utilize the SOAP  guidelines to assist you in creating your SOAP note and building your  plan of care. You are expected to develop a comprehensive SOAP note  based on the given assessment, diagnosis, and advanced nursing  interventions. Reflect on what you have learned about care plans through  independent research and peer discussions and incorporate the knowledge  that you have gained into your patient’s care plan.  If the information  is not in the provided scenario please consider it normal for SOAP note  purposes, if it is abnormal please utilize what you know about the  disease process and write what you would expect in the subjective and  objective areas of your note. SOAP Note Assignment Discussion Paper