NSG 500-Advanced health assessment Using the information from this week’s Health History assignment in Shadow Health, describe areas of the health history where you think you needed to obtain more information and discuss why that information is important for this patient. Use information below, BP 142/82, HR 86, RR 19, O2 99%, 170 CM tall, 90 KG, BMI … Read more
Week 9 Shadow Health Comprehensive SOAP Note Template Patient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): History of Present Illness (HPI): Medications: Allergies: Past Medical History (PMH): Past Surgical History (PSH): Sexual/Reproductive History: Personal/Social History: Health Maintenance: Immunization … Read more
Name: Section: Week 7 Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): In just a few words, explain why the patient came to the clinic. History of Present Illness (HPI): This is the symptom analysis … Read more
Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. HPI: This is the symptom analysis section of your note. Thorough documentation in this section … Read more