Academic Clinical Soap Notes Provide A Unique Opportunity

Question

Academic Clinical Soap Notes Provide A Unique Opportunity To Practice Develop a hospital follow-up progress SOAP note based on a clinical patient from your practicum setting. In your assessment, provide the following: A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen (Acute Care Hospital). A one- to two-paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable. List at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system. List at least five systems examined within the last 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined, and include a full set of vital signs. List all admission diagnostics conducted for this visit or within the last 24 hours (CPT codes). List all pertinent acute and chronic diagnoses in order of priority using ICD-10 codes. Identify any differential diagnoses being eliminated. Describe a treatment plan that corresponds with the diagnosis, including admission type, diagnostics, prescribed medications and dosages, and any relevant consults or follow-up procedures needed. Discuss relevant ethical, legal, or geriatric-specific considerations. Incorporate at least 3-5 peer-reviewed articles in the assessment or plan. Ensure your discussion exceeds 1200 words, uses proper academic writing, and cites sources according to APA guidelines. Include all relevant coding: ICD-10, CPT, and others. This assignment should be prepared with care to meet the expectations outlined in the grading rubric and submitted via LopesWrite.

Dr. Jack HW Helper · Accepted Answer

Hospital Follow-up Progress SOAP Note Patient Identification and Basic Information Patient ID: Jane Doe, 67-year-old female Admission Date: 10/15/2024 Service: Acute Care Hospital, General Medical Ward Chief Complaint and Working Diagnosis The primary working diagnosis is community-acquired pneumonia (ICD-10: J18.9), with pending differential diagnoses including congestive heart failure exacerbation and pulmonary embolism, being evaluated within the context of acute respiratory symptoms and radiographic findings. Current Hospital Course Jane Doe was admitted five days ago with complaints of persistent cough, fever, and shortness of breath. Initial chest X-ray revealed right lower lobe infiltrates consistent with pneumonia. Blood work showed elevated white blood cell count and C-reactive protein, indicating infection. She has been receiving empiric antibiotics (IV ceftriaxone and azithromycin) and supplemental oxygen therapy. No signs of complication or need for ventilatory support have emerged thus far. The patient’s hospital stay aims to treat the infection, assess response to therapy, and monitor for possible complications such as sepsis or cardiovascular decompensation. Systems Affected by the Diagnosis Respiratory System: Positive effects from symptom relief post-antibiotics; negative effects include hypoxia and fatigue. Cardiovascular System: No direct infection impact; however, tachycardia is observed secondary to hypoxia. Immune System: Active immune response evidenced by elevated WBC; immunosuppressed state possible due to age. Nervous System: Fatigue and malaise noted; no neurological deficits. Gastrointestinal System: Anorexia and nausea related to illness or medication side effects. Examination of Systems in the Last 24 Hours Respiratory: Increased work of breathing, oxygen saturation maintained at 92% on 2L nasal cannula. No new crackles heard. Cardiovascular: Heart rate 105 bpm, blood pressure 130/80 mmHg, no murmurs. Neurological: Lethargy but oriented

Academic Clinical Soap Notes Provide A Unique Opportunity ✓ Solved

Academic Clinical Soap Notes Provide A Unique Opportunity To Practice

Sample Paper For Above instruction

Hospital Follow-up Progress SOAP Note

Patient Identification and Basic Information

Chief Complaint and Working Diagnosis

Current Hospital Course

Systems Affected by the Diagnosis

Examination of Systems in the Last 24 Hours

Recent Diagnostic Tests (CPT Codes)

Diagnoses

Treatment Plan

Ethical, Legal, and Geriatric Considerations

References