Write SOAP notes base on the following base the following rubric… Write SOAP notes ba

Write SOAP notes base on the following base the following rubric… Write SOAP notes base on the following base the following rubric  and on the data below.  HPIDiana is a 15-year-old female, presents to the NP’s office with chief of abdominal pain x5 days. Pain radiates to umbilical area, with diarrhea, nausea and vomiting after going out with family to eat at a restaurant. Last menses was a month ago. Medication: Birth control pills   Physical Assessment Abdominal tenderness to bilateral LQ, positive rebound tenderness, positive psoas signs, Rovsing sign, Obturator sign. Negative CVA.Lips appear dry. Normal skin turgor Denies alcohol intake and smoking.  V/s. temperature 102.2, pulse 137, BP 108/58, respiration 28 Grading Rubric NURS 756 Final Checkout Student Name: _______________- Faculty: ___________________   ComponentPointsFaculty NotesGrade HPI-  student completes a well-developed  & appropriate HPI based on the chief complaint that is focused on the CC 15 Points  PMHX- requiredP/F  Meds- requiredP/F  All- requiredP/F  Immz requiredP/F  ROS- students asks a ROS that is addresses key areas of the organ systems that should be addressed based on the CC. ROS is appropriate for an episodic/acute visit20 points   Physical Exam(identify physical exam that was demonstrated, document if it was required based upon CC and HPI- note student’s ability to demonstrate exam techniques & tests based on the CC and HPI) 35 points  General   Skin   HEENT   Neck   Chest   CV   Abdomen   GU N/A  MS   Neuro     Student demonstrates exam correctly in correct order in an organized fashion with confidence20  Student is able to demonstrate appropriate tests related to exam (IE: Rinne, Murphy sign, etc) 10          Final Grade                 SOAP NOTE DOCUMENTATION GRADING SOAP  NOTEPointsFaculty feedbackGradeCC & HPI 15  PMHx, Meds, All, ImmzP/F      Subjective ROS – student documents a ROS based upon history taken during case presentation15  Physical exam: student documents exam using correct terminology, clear and accurate descriptions30   Assessment: student identifies appropriate differentials and diagnoses  based upon history and physical exam20  Plan: student documents an appropriate plan of care based upon case presentation and exam findings 10  Documentation: student documents clearly in an organized fashion, with correct terminology 10  Final Grade          Grade x __ %Final scorePhysical exam demonstration  Grade ___ x 70%= SOAP Note Grade ___ x 30%  FINAL GRADE    Health Science Science Nursing NURSING 751 Share QuestionEmailCopy link Comments (0)

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