soap for brilliant

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Week 6: Problem-Focused SOAP Note

USE the template that I gave you before. Needs the 1st blank paper for cover sheet.

Some Rubric

Some Rubric

Criteria Ratings Pts

This criterion is linked to a
Learning Outcomes (Subjective)

10 pts
Accomplished

Symptom analysis is well organized, with C/C, OLD

CART, pertinent negatives, and pertinent positives. All

data needed to support the diagnosis & differential

are present. Is complete, concise, and relevant with

no extraneous data.

10 pts

This criterion is linked to a
Learning Outcome (Objective)

10 pts
Accomplished

Complete, concise, well organized, well written, and

includes pertinent positive and pertinent negative

physical findings. Organized by body system in list

format. No extraneous data.

10 pts

This criterion is linked to a
Learning Outcome
(Assessment)

10 pts
Accomplished

Diagnosis and differential dx are correct, include ICD

code, and are supported by subjective and objective

data.

10 pts

This criterion is linked to a
Learning Outcome (Plan) 10 pts

Accomplished

Plan is organized, complete and supported with 2

evidence-based references. Addresses each diagnosis

and is individualized to the specific patient and

includes medication teaching and all 5 components:

(Dx plan, Tx plan, patient education, referral/follow-

up, health maintenance).

10 pts

Total Points: 40

Patient initial: R. R

DOB: June/1991 Sex: F

Encounter Date: 08/08/2023

SUBJECTIVE:

Chief Complaint:

History Of Present Illness:

appt is requested for URI

Medical History:

#. COVID 1/2022

#. hemorrhoids

#. Postpartum Depression, Anxiety, panic attacks

#. ADD

#. Insomnia

#. Allergic rhinitis

#. Psoriasis

#. Onychymycosis

Surgical History:

none

Gynecological History:

G2 P2 A0

Family History:

M: living, arrhythmia, palpitations

F: living, healthy

S: asthma

Social History:

-Married

-Lives with husband, 2 kids, and grandparents

-Authorization coordiinator at USC Keck, also student in digital marketing

-Denies tobacco use

-etoh use: Socially

-Denies illicit drug use

Smoking Status: Never Smoked

Allergies:

No known allergies

Current Medications:

———————————-

Paxil 10 mg po qd

xanax 0.25 mg prn panic attacks

Adderall 20mg bid prn

———————————

Review of System:

Constitutional: Patient denies weight change, fever, chills, weakness, fatigue, sleep

changes, appetite changes.

Head: Patient denies headache.

Neck: Patient denies abnormal masses, neck stiffness.

Eyes: Patient denies vision loss, blurring, discharge, excessive tearing, dryness.

Ears: Patient denies hearing loss, tinnitus, vertigo, discharge, pain

Nose: #sinus congestion#

Mouth: Patient denies ulcers, bleeding gums, taste problems.

Throat: #sore throat#

Cardiovascular: Patient denies chest pain, chest pressure, palpitations, DOE,

orthopnea.

Respiratory: #dry cough#

Patient denies shortness of breath, increased sputum, hemoptysis.

Gastrointestinal: #looser stools, frequency, occ incontinence#

Patient denies nausea, vomiting, heartburn, dysphagia, constipation, melena,

abdominal pain, jaundice, hemorrhoids.

Genitourinary: #urinary urgency and frequency, occasional incontinence#

Patient denies abnormal hesitancy, hematuria, dysuria, nocturia, stones.

Musculoskeletal: Patient denies arthralgias, joint stiffness, myalgias, muscle

weakness, instability and abnormal range of motion

Integumentary (Skin and/or Breast): Patient denies rash, lesions, changes in hair,

changes in nail, pruritus

Neurological: Patient denies headache, syncope, seizures, vertigo, ataxia, diplopia,

tremor, numbness, tingling.

Psychiatric: #depression, anxiety, ADD#

Patient denies mood abnormalities, memory loss, difficulty sleeping, appetite

changes

Endocrine: Patient denies sensitivity to cold or heat, polyuria, polydipsia.

Hematologic/Lymphatic: Patient denies bleeding, bruising, lymphadenopathy.

GYN: #menorrhagia#

Patient denies changes in menstrual cycle, hot flashes.

OBJECTIVE:

Physical Exam:

Constitutional: #last exam done on 7/10/23 showed#

WD, WN, Alert, Oriented X3 in NAD. Affect appropriate. Gait normal.

Eye: PERRLA, EOMI, nl conjunctiva

Ear: No pinnea/tragal tenderness. Drums are visualized, no wax in canals

Nose: N1 mucosa. N1 Nasal septal walls and turbinates.

Mouth: N1 bucal mucosa, no lesions noted.

Throat: Clear, no erythema or exudates.

Neck: #thyroid fullness R#

supple, no masses. Trachea is midline. N1 carotid auscultation. No JVD

Cardiovascular: RRR, N1 S1 and S2, No cardiac murmurs, rubs or gallops.

Lungs: ctab, no wheezes, rhonchi or crackles

Chest/Breasts: deferred

Gastrointestinal (Abdomen): soft, nt, nd, bs(+). No palpable masses.

Genitourinary: #negative CVAT#

deferred

Lymphatic: -No LAN noted

Musculoskeletal: good ROM. Strength symmetrical and wnl. No muscle weakness or

stiffness. No joint effusion or ttp.

Skin: Normal color and texture. No lesions seen.

Extremities: Warm, no clubbing, cyanosis or edema. N1 DP/PT pulses bilaterally

Neurological/Psychiatric: CN I-XII intact, neurosensory wnl, strength (5/5), (2+) DTR

UE/LE bilaterally -Judgment and insight intact

ASSESSMENT:

Diagnosis:

ICD-10 Codes:

1)J069; Upper respiratory infection, unspecified

PLAN:

Procedures (CPT code):

1) 99213; Detailed

2) 99401; 15 min

Medications:

Promethazine-DM 6.25-15 MG/5ML Oral Syrup; Take 5 ml orally every 4 hours Take

as needed for dry cough; Qty: 120; Refills: 0

Care Plan:

.***URI- x4 days, sore throat, sinus congestion, dry cough, headache. took

tylenol/cough syrup, claritin with not much relief. sent home today from work, COVID

test today from work pending results. sisters also similar sxs, but has tested

negative for COVID.

-off work this week

-Rx promethazine/DM 5mL prn cough, r/b d/w pt

-sudafed and tylenol prn

-f/u 1 week, if no improvement and covid neg, come back in office for exam

***urinary incontinence- h/o occasional stress incontinence, however over last 1 mo,

c/o increasing urengency, frequency and 2 episodes of incontinence, which occured

with only minimal alcohol use. denies hematuria, dysuria. c/o menorrhagia

worsening after delivering her 2 yo. denies LBP/trauma/saddle paresthesia

-pelvic floor PT ordered

-UA/UCx ordered

-referred to uro gyn

-ordered transvaginal u/s r/o uterine fibroids

-counseled on wt loss. keep voiding journal

-avoid irritants such as caffeine/ETOH

***diarrhea- c/o looser stools, 4-5xd and few episodes of incontinence. c/o abd

cramping after bm, othewise no abd pain, fever, melena, wt loss. has had h/o abd

pain and cramping which we ordered stool studies, CRP, ESR but pt never did.

denies LBP/trauma/saddle paresthesia. abd exam normal today

-ordered stool studies, ESR, CRP

-referred to GI

-ER precautions

***Hyperlipidemia, lipoprotein deficiency- On 1/16/23, FLP showed 237/47/182/156.

Has lost 6 lbs intentionally since last visit.

-Rec low fat, low carb diet

-FLP with next annual

***obesity- BMI 31.37, wt 221 lbs, Has lost 6 lbs intentionally since last visit.

-counseled

***thyroid fullness- noted on exam. 1/16/23, TSH wnl.

-ordered thyroid u/s 11/8/22, pt has not done yet

Plan Notes Continued: .

***trigger finger- unsure of duration, ono/off. R ring finger locks. Pt has seen hand

specialist in the past for another issue

-Rx ibuprofen as noted above, r/b d/w pt

-pt rec to f/u with hand specialist

***Vitamin D deficiency- On 1/16/23, Vitamin D level was 24. not supplementing.

-Rec Vitamin D 4000 IU qd

-Vitamin D level with next annual

***Onychymycosis- b/l feet on PEX on 2/1/23. pt is interested in tx.

-given the interactions between terbinafine and her psychiatric meds, I rec she

checked with them first before we start

***Depression, Anxiety- F/b psychiatrist, Dr. Askins and psychologist, Dr. Tricia

Duncan Hassle. Takes Paxil 10 mg po qd and xanax 0.25 mg prn panic attacks.

Denies SI/HI.

-mgmt per psych

***ADD- F/b psychiatrist, Dr. Askins. Takes Adderall 20mg bid prn.

-mgmt per psych

Patient Instructions: .

.

-Pt has been instructed to take medications as prescribed

-Pt received education on compliance with medications and recommendations

-Pt received counseling regarding Medication Side Effects

-Pt received counseling on following a well-balanced healthy diet with veg, fruit and

fiber.

-Pt was instructed to do CV exercise at least 3-4 times every week for 30 minutes.

PHCM: .

.

31 y/o F:

-Annual physical: done 2/1/23- next due 2/1/24

-Annual labs: done 1/16/23- next due 1/16/24

-Cervical CA screening: managed by GYN

-Skin CA screening; Referred to derm on 3/30/22

Immunizations:

Tetanus: doen 2021- next due 2031

Influenza: Fall 2022

COVID19: Pfizer in 7/1/21, bivalent booster Pfizer 1/14/23

HPV: will check records

  • Week 6: Problem-Focused SOAP Note

Reflection:

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Please see the attachment for instructions

LEADERSHIP THEORIES IN PRACTICE

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 A walk through the Business section of any bookstore or a quick Internet search on the topic will reveal a seemingly endless supply of writings on leadership. Formal research literature is also teeming with volumes on the subject.

However, your own observation and experiences may suggest these theories are not always so easily found in practice. Not that the potential isn’t there; current evidence suggests that leadership factors such as emotional intelligence and transformational leadership behaviors, for example, can be highly effective for leading nurses and organizations.

Yet, how well are these theories put to practice? In this Discussion, you will examine formal leadership theories. You will compare these theories to behaviors you have observed firsthand and discuss their effectiveness in impacting your organization.

To Prepare:

  • Review the Resources and examine the leadership theories and behaviors introduced.
  • Identify two to three scholarly resources, in addition to this Module’s readings, that evaluate the impact of leadership behaviors in creating healthy work environments.
  • Reflect on the leadership behaviors presented in the three resources that you selected for review. Post two key insights you had from the scholarly resources you selected. Describe a leader whom you have seen use such behaviors and skills, or a situation where you have seen these behaviors and skills used in practice. Be specific and provide examples. Then, explain to what extent these skills were effective and how their practice impacted the workplac

Module 6 case study-5550

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Read the following case study and answer the reflective questions.  Please provide evidence-based rationales for your answers.  APA, 7th ed. must be followed. 

My Plan Reflection

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Introduction

There are so many potential careers in healthcare, choosing one that will make you happy means finding one that fits your personality as well as your goals. The earlier you plan for the career you want the more successful you will be in pursuing it. There are many things to consider when thinking about a career, of course, there are the skills and education you need to have, which we will discuss in depth in this course, but there are other questions to consider as well. What do you want to do every day? Would you like to sit at a desk, work with people one-on-one or would you rather work with groups? Do you like teaching? For example, where do you want to work, a hospital, office, or community center?  What kind of people do you want to work with, children, adults, or the elderly? Is there a specific segment of the population you enjoy working with such as veterans, special needs children, or handicapped? Do you want to travel or would you rather have a job that keeps you in one setting all day or in a residential facility?   In this chapter, you should think about the aspects of your career that you want to shape your life and how you work.  You will begin by analyzing your personality so you can narrow down career choices based on compatibility with your personality.  By the end of this chapter, we hope you have a checklist of important things to make choosing a career easier for you.

Briefly, in one paragraph (no more), describe your feelings about your My Plan results. Specifically: How did you feel about the results? Were you surprised by any aspect of the results? Were some aspects what you expected? BE SPECIFIC about your feelings. Thinking back to the last module, when you submitted your initial thoughts on your chosen career, how well do the results align with your current career intentions? As a result of the career assessments, are you considering any changes to your career plans?

The results of the My Plan Personality assessment are ESFJ.

Emotional Focus:???? Extroverted (E)

Information Gathering:???? Sensor (S)

Decision Making:???? Feeler (F)

Structural Orientation:???? Judgers (J)

The top two career results of the MY Plan career interest inventory assessment are Conventional and Social.

week 7 discussion answers

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Please respond to each discussion post with 4 to 5 sentences with apa references for each 

Spending and the Healthcare Economy

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Healthcare spending in the United States has continued to increase over the past several decades at a rate that far exceeds that of other nations. People have seen these increases on everything, from the cost of insurance premiums going up, to the costs of drug prices and office visits increasing. To familiarize yourself with some of the many areas and ways costs and spending are increasing, please review the NHE fact sheet.

  • Discuss 1 area that you or someone close to you have seen these increases in costs.
  • Examine these increased costs from the perspective of the leader of a healthcare organization. Consider the following:
    • Why do you feel there was an increase in the cost?
    • What, if anything, could have been done to react to the rise in costs and decrease their impact on the organization?
    • What can the organization do to help avoid these increases in the future?

Nursing The future of nursing informatics in nursing practice assignment

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In the past, treating the whole person, with sensitivity to the interplay of biological, psychological, social, and cultural factors that impact health and healing, has been central to the practice of nursing. The field of informatics is playing an important role in advancing our understanding of human health and well-being by utilizing advanced computational modeling and data analytics to improve health care delivery as shown in this nursing informatics assignment help. In the future, informatics will enable nurses to better identify and respond to the unique needs of their patients and patients around the world, using data analytics to personalize care.

The field of informatics is the study of information and its application in the healthcare industry. Formerly, the focus of the field was on how to organize, store, and retrieve data in EHRs. Today, the focus is on the use of data and analytics to drive better clinical care and outcomes, improve workflow, and build more efficient care delivery systems. The field is also advancing in its treatment of informatics as a science and engineering, with the potential to create breakthroughs in diagnosis and treatment (Brewer, Fortuna, Jones, Walker, Hayes, Patten, & Cooper, 2020).

In the past, the role of informatics was to store and retrieve patient information. Today, the role of informatics is to improve the care provided to patients by using data and analytics to drive better clinical care and outcomes, improve workflow, and build more efficient care delivery systems (Brewer, et al., 2020). Nurses are using data and analytics to improve the quality of care they provide and the outcomes they achieve, while simultaneously improving the efficiency with which they deliver care. They’re also applying machine learning and predictive analytics to improve care coordination and patient outcomes.

Previously, the focus of the field of informatics has been on the collection and analysis of electronic health information. This has led to the development of electronic health records (EHR) and clinical decision support systems, which are used to improve the quality of care provided to patients (Backonja, Mook, & Heermann Langford, 2021). However, treating the patient as the center of care has been the guiding principle of nursing for centuries. The field of informatics builds on that tradition by providing the tools and information necessary to optimize care, improve patient outcomes, and reduce costs.

Treating the whole person, with sensitivity to the interplay of biological, psychological, social, and cultural factors that impact health and healing, is central to the practice of nursing. The growing field of informatics is playing a critical role in advancing our understanding of human health and well-being by utilizing advanced computational modeling and data analytics to improve health care delivery (Backonja, Mook, & Heermann Langford, 2021, Nursing Assignment Help). In the future, informatics will enable nurses to better identify and respond to the unique needs of their patients and patients around the world, using data analytics to personalize care. 

Tens of thousands of nurses across the country are working to advance the state of informatics in nursing practice. Nurses are using data and analytics to drive better clinical care and outcomes, improve workflow, and build more efficient care delivery systems. They’re also applying machine learning and predictive analytics to improve care coordination and patient outcomes. And they’re using chatbots and virtual assistance to provide high-quality care when and where it’s needed most (Backonja, Mook, & Heermann Langford, 2021).

Tackling some of the biggest challenges in nursing practice through the use of technology is the key to improving care and outcomes for patients. The field of informatics is the study of information, including how it is gathered, analyzed and applied (Brewer, et al., 2020). Advances in informatics have led to some of the most significant improvements in care and health outcomes in the history of medicine. The field is developing at a breakneck pace, and with it comes the opportunity to transform the way we practice.

Treating informatics as an engineering discipline has led to a number of innovations in the field, including the creation of electronic health records (EHR) and clinical decision support systems. However, treating informatics as a science has also led to some promising advancements in the field, including the development of artificial intelligence (AI) algorithms to diagnose and treat disease (Kiessling, Iott, Pater, Toscos, Wagner, Gottlieb, & Veinot, 2022).. The most exciting developments in the future of informatics are likely to be those that are developed in the intersection of the two: treating informatics as a science and engineering, and treating informatics as a humanistic discipline and art. As such, informatics will continue to play an important role in nursing practice, with a focus on advancing the field as a whole, not just as a technology to be

Treating the patient as the center of care has been the guiding principle of nursing for centuries. The field of informatics builds on that tradition by providing the tools and information necessary to optimize care, improve patient outcomes, and reduce costs. As the field of informatics continues to grow and evolve, so too does the future of nursing. What will the field look like in the future? Reference: https://profsonly.com/assignment-help/nursing-assignment-help-from-expert-writers/nursing-informatics-assignment-help-by-expert-writers/ 

  

Nursing informatics and health informatics

The field of nursing known as “nursing informatics” focuses on integrating information technology with traditional nursing practises. The role of the nurse informaticist in modern healthcare is to facilitate communication between the organization’s IT infrastructure and the clinicians and other providers working inside it. It can mean different things to different people, but put simply, it’s the use of computers and nursing science to disseminate data, knowledge, and expertise in the field of nursing. Both health informatics and nursing informatics make use of data and technology to facilitate change that could enhance care delivery, result in better health for patients, and reduce healthcare costs. However, health informatics is a broad phrase that encompasses a variety of disciplines, occupations, and data-driven healthcare innovations.

Why nurses should have nursing informatics

Nursing informatics influences workflow, facilitates communication between IT and nurses, and increases patient acceptance of routine clinical processes. Facilitates enhanced nursing care for patients.

Good healthcare depends on accurate and comprehensive electronic health records. By adhering to privacy regulations, informaticians ensure that hospitals and clinics have the infrastructure in place to store and track extensive medical records for each patient.

Guiding principles in nursing informatics

According to American Nurses Association, the guiding principle that nurses need to follow as it pertains to nursing informatics include, Assessment, Diagnosis, problems, and issues identification, Outcomes identification, planning, implementation and evaluation.

How nursing informatics is linked to quality and patient safety

The results of the study performed by python assignment help demonstrate the critical importance of IT literacy for enhancing healthcare delivery. Nursing education programmes that incorporate technology and multimedia can help increase the usage of informatics tools in practise, which in turn protects patients. Several studies have shown that shift planning and management have an impact on nurses’ productivity and the quality of healthcare provided.

  

References

Backonja, U., Mook, P., & Heermann Langford, L. (2021). Calling nursing informatics leaders: Opportunities for personal and professional growth. OJIN: The Online Journal of Issues in Nursing, 26(3), 1-8. Profsonly.com/assignment-help/nursing-assignment-help-from-expert-writers/

Brewer, L. C., Fortuna, K. L., Jones, C., Walker, R., Hayes, S. N., Patten, C. A., & Cooper, L. A. (2020). Back to the future: achieving health equity through health informatics and digital health. JMIR mHealth and uHealth, 8(1), e14512. https://profsonly.com/assignment-help/python-assignment-help/ 

Kiessling, K. A., Iott, B. E., Pater, J. A., Toscos, T. R., Wagner, S. R., Gottlieb, L. M., & Veinot, T. C. (2022). Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want. JAMIA open, 5(1), ooac007.

  

RESPONSE TO DISCUSSION BOARD 5

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Use the attached document to provide responses to the discussion board. please provide 2 scientific references in APA format.

Nursing homework

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I want this assignment in PowerPoint pls.