For faster services, inquiry about  new assignments submission or  follow ups on your assignments please text us/call us on +1 (251) 265-5102

Soap Note of adult wellness

The post Soap Note of adult wellness is a property of College Pal
College Pal writes Plagiarism Free Papers. Visit us at College Pal – Connecting to a pal for your paper

Soap Note of adult wellness ( Nurse Practitioner)

Use APA format and must include with minimum of 2 Scholarly Citations.

MRUSoapNoteRubric2021-1.docx

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Soap Note of adult wellness appeared first on College Pal. Visit us at College Pal – Connecting to a pal for your paper

Generated by Feedzy

CLAIM YOUR 25% OFF TODAY

X
IntaSend Secure Payments (PCI-DSS Compliant) Secured by IntaSend Payments
WeCreativez WhatsApp Support
Our customer support team is here to answer your questions. Ask us anything!
👋 Hi, how can I help?