Running Head: Name Of Care Plan 1 Title Of Plan Of Care

Question

Running Head Name Of Care Plan 1title Of Plan Of Carenamesouth Unive Extracted and cleaned assignment instructions: Create a comprehensive care plan document that includes subjective data (patient-reported information), objective data (vital signs, physical assessment findings, laboratory and diagnostic test results), assessment with at least three priority diagnoses (including ICD-10 codes), and a detailed plan of care for each diagnosis. The plan should address diagnostic and therapeutic management as well as education and counseling provided, based on the detailed patient information outlined above. Ensure the care plan is well-structured, covers all necessary sections, and includes references to credible sources.

Dr. Jack HW Helper · Accepted Answer

Title of Care Plan Patient Initials: ______ Subjective Data The subjective data collection involves gathering information directly from the patient regarding their health status and concerns. This includes the chief complaint, which should be recorded verbatim in the patient's own words to accurately capture their primary concern. The history of present illness (HPI) provides a chronological analysis of current problems, detailing onset, location, frequency, quality, quantity, aggravating and alleviating factors, associated symptoms, and previous treatments undertaken. Comprehensive past medical history encompasses ongoing medications, allergies, previous illnesses, hospitalizations, surgeries, psychiatric history, and obstetric and sexual histories. Family history should detail specific inheritable conditions present within the patient's family, such as genetic disorders or chronic diseases. The social history captures the patient's living conditions, marital status, cultural background, health behaviors, lifestyle, religious practices, education, occupational history, financial situation, and any history of family violence. Review of Systems This systematic review evaluates each bodily system, beginning with positive findings and then denying symptoms. Systems include general health, integumentary, head, eyes, ears/nose/throat (ENT), cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, endocrine, hematologic, and psychological. Objective Data Objective data involves measurable information such as vital signs: blood pressure, pulse, respiration rate, temperature, weight, height, and BMI. The physical examination should be a head-to-toe review including HEENT, lymph nodes, carotids, lungs, heart, abdomen, genital/pelvic region, rectum, extremities (pulses), and neurological assessment. Laboratory and diagnostic test results should be included with their respective interpretations. Assessment This section requires the identific

Running Head: Name Of Care Plan 1 Title Of Plan Of Care ✓ Solved

Running Head Name Of Care Plan 1title Of Plan Of Carenamesouth Unive

Sample Paper For Above instruction

Patient Initials: ______

Subjective Data

Review of Systems

Objective Data

Assessment

Plan of Care

References