Instructions: Select one of the topic mentioned below and discuses filling the attached form.
Ø The discussion must address the topic
Ø Rationale must be provided
Ø Use at least 600 words (no included 1st page or references in the 600 words)
Ø May use examples from your nursing practice
Ø Formatted and cited in current APA 7
Ø Use 3 academic sources, not older than 5 years. Not Websites are allowed.
Ø Plagiarism is NOT permitted
Soap Note # ____ Main Diagnosis ______________
Gender at Birth:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition. Make a paragraph
Differential diagnosis (minimum 4) make a paragraph for each one
Labs and Diagnostic Test to be ordered (if applicable)
Education (provide the most relevant ones tailored to your patient)
References (in APA Style)
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