I am having a hard time doing a soaps note with the following information for my medical terminology class. REVISIT PATIENT COMPLAINTS AND ANY EVALUATIVE INFORMATION • DEVELOP PROBLEM LIST AND DIFFERENTIAL DIAGNOSIS • WHAT IS YOUR DIAGNOSTIC PLAN? • WHAT IS YOUR THERAPEUTIC PLAN? • PATIENT EDUCATION?
I am having a hard time doing a soaps note with the following information for my medical terminology class. REVISIT PATIENT COMPLAINTS AND ANY EVALUATIVE INFORMATION • DEVELOP PROBLEM LIST AND DIFFERENTIAL DIAGNOSIS • WHAT IS YOUR DIAGNOSTIC PLAN? • WHAT IS YOUR THERAPEUTIC PLAN? • PATIENT EDUCATION?
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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Question
I am having a hard time doing a soaps note with the following information for my medical terminology class.
REVISIT PATIENT COMPLAINTS AND ANY EVALUATIVE INFORMATION • DEVELOP PROBLEM LIST AND DIFFERENTIAL DIAGNOSIS • WHAT IS YOUR DIAGNOSTIC PLAN? • WHAT IS YOUR THERAPEUTIC PLAN? • PATIENT EDUCATION?
Transcribed Image Text:VITAL SIGNS WHILE LYING SUPINE
BP=122/80 MMHG, HR=82,
RR=12BPM, TEMP=98.2°
YOU ASK THE PATIENT TO SIT UP IN
PATIENT
BED TO RETAKE HIS BLOOD
PRESSURE AND LISTEN TO HIS
LUNGS (HE TELLS YOU HE CAN SIT
UP ON HIS OWN)
EVALUATION
BP=98/64 MMHG BLOOD
PRESSURE DECREASE OF
20 MM HG OR A DI
CONTINUED
BLOOD PRES
EREASE OF
M HG WITHIN
MINUTES OF STANDING
LUNG SOUNDS NORMAL
SKIN WITHOUT BLUE TINGE OF
COLOR, FLUID ACCUMULATION
UNDER THE SKIN, OR
ABNORMALLY PALE COLOR OF THE
SKIN.
Transcribed Image Text:NURSING ADMISSION NOTE:
patient number: QU3876
• Pt. is a 30 y/o male who lives alone in an apartment
with primary complaint of decreased functional mobility.
Pt. was recently treated at the urgent care center
located in the local Walmart following a fall while
CHART
getting out of bed the week before. He was taken to
the center by his friend that lives in the same building.
REVIEW
Secondary complaints of:
intermittent headache
• High sensitivity to pain
• Tingling feeling
• Passing out
English Speaking
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