Assignment: Online Expanded Typhon Case Logs & Soap Notes

Assignment: Online Expanded Typhon Case Logs & Soap Notes ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Online Expanded Typhon Case Logs & Soap Notes Expanded Typhon Case Logs (SOAP) Create 11 different Soap notes addressing different pediatric health issues (Pediatric only. The soap notes must address the women population only. Please address the ROS(review of systems),Include OB history if any, and PE(physical examination).In your soap template include medications, ICD 10 diagnosis codes ,CPT billing codes and referrals if needed. Include prescribing dosage Assignment: Online Expanded Typhon Case Logs & Soap Notes Notes should vary and address different Pediatric health issues, include developmental stage You may not repeat a topic more than twice. Notes are evaluated by a scoring rubric (see attached) _geriatric__health_expanded_typhon_case_logs.docx Expanded Typhon Case Logs (SOAP) • Create 10 different Soap notes addressing different Geriatric health issues The soap notes must address the Geriatric health population only. Please address the ROS(review of systems),Include OB history if any, and PE(physical examination).In your soap template include medications, ICD 10 diagnosis codes ,CPT billing codes and referrals if needed. Notes should vary and address different health issues You may not repeat a topic more than twice. • Notes are evaluated by a scoring rubric (see attached) • Construction of your SOAP note should be aimed at achieving a score of “proficient” in each category. Failure to achieve a proficient rating for each of the evaluation criterion, represented in the rubric, by the end of the course will require revision of the final SOAP note submitted until successful. Failure to do so results in failure meet the clinical requirements of the course and failure of the course. Documentation Requirements ALL Typhon Case Logs Must Include: Patient Demographics Section: o Age o Race o Gender Clinical Information Section: o Time with Patient o Consult with Preceptor o Type of Decision Making o Student Participation o Reason for visit o Chief Complaint o Social Problems Addressed Medications Section: o # OTC Medications taken regularly o # Prescriptions currently prescribed o # New/Refilled Prescriptions This Visit ICD 10 Codes Category: o For each diagnosis addressed at the visit CPT Billing Codes Category: o Evaluation and management code o – Procedure codes (Pap smear, destruction of lesion, sutures, vaccination administration, etc.) Other Questions About This Case Category: o Age Range Revised 1/3/19 o Patient type o HPI o Patients Primary Language • • • ? Notes are evaluated by a scoring rubric ? Construction of your SOAP note should be aimed at achieving a score of “proficient” in each category. Failure to achieve a proficient rating for each of the evaluation criterion, represented in the rubric, by the end of the course will require revision of the final SOAP note submitted until successful. Failure to do so results in failure meet the clinical requirements of the course and failure of the course. SOAP Note Format All sections should be addressed as pertinent to the presenting chief complaint. Refer to the rubric and the format below. *Subjective: CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased. HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary] PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, and routes of administration. Revised 8/31/18 4 Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Health Maintenance/Promotion: (Required for annual wellness or physical exams.) Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. ROS: review of systems – this is to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness. You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. Assignment: Online Expanded Typhon Case Logs & Soap Notes While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/categories applicable to your patient’s chief complaint. General: May include if patient has had a fever, chills, fatigue, malaise, etc. Skin: HEENT: head, eyes, ears, nose and throat Neck: CV: cardiovascular Lungs: GI: gastrointestinal GU: genito-urinary PV: peripheral vascular MSK: musculoskeletal Neuro: neurological Endo: endocrine Psych: *Objective: AVOID USING”WNL,Normal Findings, write out all findings even if its normal PE: physical exam – either limited for a focused exam or more extensive for a complete history and physical assessment. This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical Revised 8/31/18 5 examination of CV and lungs. While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint. Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory. Gen: general statement of appearance, if there is any acute distress. VS: vital signs, height and weight, BMI Skin: HEENT: head, eyes, ears, nose and throat Neck: CV: cardiovascular Lungs: Abd: abdomen GU: genito-urinary PV: peripheral vascular MSK: musculoskeletal Neuro: neurological exam Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.). *Assessment: Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis. A statement of current condition of all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the S and O must support this diagnosis. Pertinent positives and negatives must be found in the write-up. *Plan: These are the interventions that relate to each individual 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 dosing information, including quantity and number of refills for any new or refilled medications. Pay attention to pediatric dosage. Reminder: Clinical documentation is confidential. Educational: information clients need in order to address their health problems. Include followup 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. SOAP Note Evaluation Rubric Criterion Highly Proficient ICD-10 Code ICD-10 Code ICD-10 Code provided that provided with is congruent appropriate with clinical modifiers information congruent with provided but the clinical fails to information demonstrate provided appropriate modifiers Proficient Marginally Proficient Approaching Proficiency ICD-10 Code provided with limited clinical information detail ICD-10 code provided that ICD-10 Code is not provided ICD-10 Code congruent with without clinical not provided the clinical information information provided Not Proficient Not evident Faculty Feedback: CPT Code N/A Clinical information provided is congruent with and supports the CPT Code identified in the encounter Clinical information provided is either not congruent with N/A or does not support the CPT Code identified in the encounter Clinical information provided is not congruent with CPT Code not and does not provided support the CPT Code identified in the encounter Faculty Feedback: All elements of All elements of All elements of All elements of All elements of No elements subjective data subjective data subjective data subjective data subjective data of subjective (CC, HPI, PMH, (CC, HPI, PMH, (CC, HPI, PMH, (CC, HPI, PMH, (CC, HPI, PMH, data (CC, HPI, Allergy Allergy Allergy Allergy Allergy PMH, Allergy identification, identification, identification, identification, identification, identification, Subjective Medication Medication Medication Medication Medication Medication Data Reconciliation, Reconciliation, Reconciliation, Reconciliation, Reconciliation, Reconciliation, Social History, Social History, Social History, Social History, Social History, Social History, Family History, Family History, Family History, Family History, Family History, Family History, Health Health Health Health Health Health Promotion, Promotion, Promotion, Promotion, Promotion, Promotion, and ROS) are and ROS) are and ROS) are and ROS) are and ROS) are and ROS) are adeptly documented and demonstrate consistent information appropriately satisfactorily documented documented and but do not demonstrate either not satisfactorily documented or do not satisfactorily documented and do not demonstrate provided in the assignment August 2018 across all aspects represented demonstrate consistent information across all aspects represented consistent information across all aspects represented not demonstrate consistent information across all aspects represented consistent information across all aspects represented Faculty Feedback: Objective Assignment: Online Expanded Typhon Case Logs & Soap Notes Data All elements of All elements of objective data objective data are are adeptly appropriately documented documented and and demonstrate demonstrate consistency consistency relative to the relative to the information information documented documented in in the CC, HPI, the CC, HPI, PMH, and ROS PMH, and ROS All elements of All elements of All elements of objective data objective data objective data are are either not are not satisfactorily satisfactorily satisfactorily No elements documented documented documented of objective but do not or do not and do not data are demonstrate demonstrate demonstrate provided in consistency consistency consistency the relative to the relative to the relative to the assignment information information information documented in documented in documented in the CC, HPI, the CC, HPI, the CC, HPI, PMH, and ROS PMH, and ROS PMH, and ROS Faculty Feedback: Assessment designations and other elements in this section are adeptly documented Assessment and demonstrate congruence with information documented in the CC, HPI, Assessment designations and other elements in this section are appropriately documented and demonstrate congruence with information documented in the CC, HPI, Assessment Assessment Assessment designations designations designations and other and other and other Assessment elements in elements in elements in designations this section this section are this section and other are either not are not elements in satisfactorily satisfactorily satisfactorily this section documented documented documented are not but do not or do not and do not provided in demonstrate demonstrate demonstrate the congruence congruence of congruence of assignment with information information information documented in documented in documented in the CC, HPI, the CC, HPI, PMH, ROS, PMH, ROS, and the CC, HPI, PMH, ROS, and PMH, ROS, and and the the objective PMH, ROS, and the objective the objective objective data data the objective data data data Faculty Feedback: August 2018 Plan Faculty Feedback: Elements of the plan are adeptly documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented Elements of the Elements of the Elements of the Elements of the plan are plan are either plan are not plan are satisfactorily not satisfactorily appropriately documented satisfactorily documented, documented, but either do documented, or do not demonstrate not do not demonstrate application of demonstrate demonstrate application of current clinical application of application of Elements of current clinical practices for current clinical current clinical a plan are practices for the identified practices for practices for not the identified assessment the identified the identified provided in assessment designations, assessment assessment the designations, and designations, or designations, or assignment and do not demonstrate do not do not demonstrate congruence of demonstrate demonstrate congruence of information congruence of congruence of information across all information information across all aspects across all across all aspects represented aspects aspects represented represented represented … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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