04 Aug Adult Wellness Check Up Soap Note

Soap Note 1 Adult Wellness Check up

Must use the sample template for your soap note,

Follow Soap Note Rubric as a guide

Use APA format and must include a minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 25% or will not be accepted for credit.

The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.

•  Apply knowledge to differentiate subjective and objective information to construct an accurate and thorough past medical history (PMH), history of present illness (HPI) and physical examination (PE).
•  Formulate accurate differential diagnoses to promote health, prevent disease, and manage acute and chronic illness in adult and geriatric population.
•  Employs screening and diagnostic strategies in the development of diagnoses.
•  Demonstrate effective communication skills by performing culturally sensitive health assessment interviews.
•  Critically analyze data and evidence for improving health outcomes.EPSLO’S

•  I – Integrate nursing and related sciences into the delivery of care to clients in diverse healthcare settings.
•  II- Create effective interdisciplinary organizational and systems leadership in the care of clients in diverse care settings.
•  IV- Apply practice guidelines to improve practice and health outcomes.
•  V- Relate information and communication technologies to document and improve practice health outcomes
  •  VII – Employ collaborative interprofessional strategies for improving client and population health outcomes.
  •  VIII – Evaluate the effectiveness of clinical prevention interventions that affect individual and population based-health outcomes, perform risk assessments, add design plans or programs of care.
  •  XI – Relate knowledge of illness and disease management to providing evidence-based care to clients, communities, and vulnerable populations in an evolving healthcare delivery system