Tag: Nursing

[Solved] Reply 1, Diagnosis week 5

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Reply to the following discussion, no AI, APA style, less than 20 %, plag, 2 or more references. 1.- The correct answer is **A**. Nehineza, which is least likely to be at risk for developing Osteoporosis, this patient is an overweight African American female with a family history of uterine cancer, …

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Reply to the following discussion, no AI, APA style, less than 20 %, plag, 2 or more references.
1.- The correct answer is **A**. Nehineza, which is least likely to be at risk for developing Osteoporosis, this patient is an overweight African American female with a family history of uterine cancer, is the least likely to be at risk. Research indicates that African American women typically exhibit higher bone mineral density, and increased body weight contributes mechanical loading that helps protect against bone loss. Additionally, her family history of uterine cancer does not directly correlate with an elevated risk for osteoporosis (National Osteoporosis Foundation, 2021).
2. Densitometry results are reported as T-scores. T-scores that fall between -1.0 and -2.5 are classified as indicative of osteopenia, demonstrating a moderate reduction in bone mineral density that does not reach the threshold for osteoporosis (Cosman et al., 2022).
Following a prompt analysis of this patient, I have determined the need to initiate treatment for osteoporosis.
3.-The first-line pharmacologic therapy for this condition is bisphosphonates, such as alendronate and risedronate, given their proven efficacy in reducing fracture risk (Eastell et al., 2021). Before starting therapy, it is essential to evaluate the patient for any contraindications, including esophageal abnormalities, hypocalcemia, and renal impairment (McClung & Saag, 2024). Additionally, ensuring adequate intake of calcium and vitamin D is crucial.
Patients should be instructed to take bisphosphonates with plain water on an empty stomach and to remain upright for at least 30 minutes to reduce the risk of gastrointestinal irritation (Khan et al., 2023).
Renal function should be assessed, as bisphosphonates are contraindicated for patients with a creatinine clearance of less than 30 to 35 mL/min. Laboratory tests should include serum levels of calcium, phosphate, magnesium, and 25-hydroxyvitamin D. Additionally, a dental examination is recommended to check for potential jaw problems before initiating treatment before starting treatment. Baum, S. J. (2023, January 5).

November 5, 2026
[Solved] Reply 2, Diagnosis week 5

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Reply to the following discussion, no AI, APA style, less than 20 %, plag, 2 or more references. **Comprehensive Overview of Osteoporosis Risks, Diagnosis and Treatment** Osteoporosis is a disease that has seen a surge in recent times. It is a disease characterized by reduced bone mass and deteriora…

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Reply to the following discussion, no AI, APA style, less than 20 %, plag, 2 or more references.
**Comprehensive Overview of Osteoporosis Risks, Diagnosis and Treatment**
            Osteoporosis is a disease that has seen a surge in recent times. It is a disease characterized by reduced bone mass and deterioration of bone structure and architecture. Based on the four patients listed, the one with the least likelihood of being at risk for osteoporosis is Nehineza. The first factor that hints toward this is the fact that she is overweight (Sabri et al., 2023). For the body to support large amounts of weight, it often increases bone mass to the maximum due to the weight they have to carry. This situation also comes with a high production of estrogen, which is a protective factor against osteoporosis.
            It is also important to consider that the other patients also have factors that increase the risk of the illness. Cristina has a sedentary lifestyle, which increases the chance of developing the disease (Sabri et al., 2023). Park-Gim-Ka has low body weight and smokes, while Skyler is in the early stages of menopause. All of these are factors that increase the chances of developing the illness.
            Densitometry shows the strength of the bones, with a T-score of 0 to -1.0 being normal. On the other hand, anything between the range of -1.1 and -2.5 means that the bones are getting weaker and thinner. This is often a sign of osteopenia (Foessi et al., 2023). In this case, the medical staff can begin to introduce certain interventions to strengthen the bones, including abstinence from alcohol and smoking, with an increased calcium and vitamin D intake. If the T-scores of the densitometry show a score of less than -2.5, it is a definitive sign that the person has developed osteoporosis, where the interventions are more stringent and include medications along with strict lifestyle changes (Foessi et al., 2023).
            In the treatment of osteoporosis, the first-line of treatment with regard to medication is bisphosphonates. These medications slow bone loss by stopping osteoclast-mediated bone resorption (Chen et al., 2024). This aids in maintaining bone density. However, there are a variety of considerations to take into account before administering these medications. The first is the kidney function. Bisphosphonates are not recommended for patients with kidney issues (Chen et al., 2024). In addition, it is important to consider the esophageal and dental health, as these medications can hurt the teeth and irritate the esophagus.
            The recommendations for patients on these medications are to take the medications first thing in the morning on an empty stomach with strictly water, nothing else (Chen et al., 2024). The patient must not eat, drink, or take any other medications for at least forty minutes. The patient should try to stay upright to reduce the risk of esophageal irritation. They should also stay in line with their exercise routine and take enough calcium and vitamin D.

November 5, 2026
[Solved] Rw soap note week 4

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Rw soap note week 4 – ## NU611WeeklySOAPnoteinstructionsWeeks234-rev320232.docx – ## SOAPNoteTemplate-Final3.docx **## NU611WeeklySOAPnoteinstructionsWeeks234-rev320232.docx** Over the course of the semester you will choose 1 patient encounter each week to document an extended SOAP note for. In Week…

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Rw soap note week 4

– ## NU611WeeklySOAPnoteinstructionsWeeks234-rev320232.docx

– ## SOAPNoteTemplate-Final3.docx

**## NU611WeeklySOAPnoteinstructionsWeeks234-rev320232.docx**

Over the course of the semester you will choose 1 patient encounter each week to document an extended SOAP note for. In Weeks 2, 3, and 4, you will submit only the subjective and objective data sets for your chosen encounter.

It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.

Each SOAP note carries a 30-point value.

SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.

For planned weekly clinical experiences submission of the SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 2 through week 7.

For planned and approved condensed, compressed or alternate clinical experiences, submission of the SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.

**## SOAPNoteTemplate-Final3.docx**

| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |

| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |

| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |

| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |

| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |

| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| PREVENTITIVE <br> <br>(Used for comprehensive exams) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |

**## SOAPNoteTemplate-Final3.docx**

| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |

| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |

| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |

| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |

| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |

| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| PREVENTITIVE <br> <br>(Used for comprehensive exams) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |

**## NU611WeeklySOAPnoteinstructionsWeeks234-rev320232.docx**

Over the course of the semester you will choose 1 patient encounter each week to document an extended SOAP note for. In Weeks 2, 3, and 4, you will submit only the subjective and objective data sets for your chosen encounter.

It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.

Each SOAP note carries a 30-point value.

SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.

For planned weekly clinical experiences submission of the SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 2 through week 7.

For planned and approved condensed, compressed or alternate clinical experiences, submission of the SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.

**## SOAPNoteTemplate-Final3.docx**

| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |

| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |

| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |

| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |

| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |

| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| PREVENTITIVE <br> <br>(Used for comprehensive exams) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |

**## NU611WeeklySOAPnoteinstructionsWeeks234-rev320232.docx**

Over the course of the semester you will choose 1 patient encounter each week to document an extended SOAP note for. In Weeks 2, 3, and 4, you will submit only the subjective and objective data sets for your chosen encounter.

It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.

Each SOAP note carries a 30-point value.

SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.

For planned weekly clinical experiences submission of the SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 2 through week 7.

For planned and approved condensed, compressed or alternate clinical experiences, submission of the SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.

**## SOAPNoteTemplate-Final3.docx**

| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |

| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |

| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |

| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |

| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |

| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| PREVENTITIVE <br> <br>(Used for comprehensive exams) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |

– 1
– 2

November 5, 2026
[Solved] Rw soap note week 4

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November 5, 2026
[Solved] Rw soap note week 4

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November 5, 2026
[Solved] disc6

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The patient is a 71-year-old widowed man who is seen regularly in the clinic for health maintenance and follow-up of his chronic insomnia and anxiety. He has regular prescriptions for triazolam (Halcion) and clonazepam (Klonopin) for these problems. Recently he has been reporting frequent episodes o…

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The patient is a 71-year-old widowed man who is seen regularly in the clinic for health maintenance and follow-up of his chronic insomnia and anxiety. He has regular prescriptions for triazolam (Halcion) and clonazepam (Klonopin) for these problems. Recently he has been reporting frequent episodes of losing his balance and falling, and eight weeks ago was hospitalized for a hip fracture sustained during one of these falls resulting in hip surgery. On this visit, he also complains of becoming increasingly confused.
– What information would be most critical for you to collect in the first visit?
– What is the primary goal for the treatment of this patient?
– Identify potential obstacles for change. Which educational approach would the PMHNP provide to overcome these obstacles?
– How would you teach the patient about the Beers list and Halcion?
– Discuss a medication in detail that could be safely substituted to treat insomnia in geriatric patients.
– Your initial post should be at least 500 words, formatted and cited in current APA style.
– Provide support for your work from at least 2 academic sources less than 5 years old.

November 5, 2026
[Solved] The Role of the Nurse Informaticist in Systems Development and Implementation

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_Assume you are a nurse manager on a unit where a new nursing documentation system is to be implemented. You want to ensure that the system will be usable and acceptable for the nurses impacted. You realize a nurse leader must be on the implementation team._ **To Prepare:** – Review the steps of the…

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_Assume you are a nurse manager on a unit where a new nursing documentation system is to be implemented. You want to ensure that the system will be usable and acceptable for the nurses impacted. You realize a nurse leader must be on the implementation team._
**To Prepare:**
– Review the steps of the Systems Development Life Cycle (SDLC) and reflect on the scenario presented.
– Consider the benefits and challenges associated with involving a nurse leader on an implementation team for health information technology.
**The Assignment: (2-3 pages not including the title and reference page)**
In preparation of filling this role, develop a 2- to 3-page role description for a graduate-level nurse to guide his/her participation on the implementation team. The role description should be based on the SDLC stages and tasks and should clearly define how this individual will participate in and impact each of the following steps:
– Planning and requirements definition
– Analysis
– Design of the new system
– Implementation
– Post-implementation support
– Use APA format and include a title page and reference page.
– Use the Turnitin Drafts to check your match percentage before submitting your work.
Weekly Resources
– McGonigle, D., & Mastrian, K. G. (2022). _Nursing informatics and the foundation of knowledge_ (5th ed.). Jones & Bartlett Learning.
– Chapter 9, “Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making” (pp. 191–204)
– Chapter 12, “Electronic Security” (pp. 251–265)
– Chapter 13, “Achieving Excellence by Managing Workflow and Initiating Quality Projects”
– Agency for Healthcare Research and Quality. (n.d.a). [_Health IT evaluation toolkit and evaluation measures quick reference guide_Links to an external site.](https://digital.ahrq.gov/health-it-evaluation-toolkit). Retrieved January 26, 2022, from https://digital.ahrq.gov/health-it-evaluation-toolkit
– Agency for Healthcare Research and Quality. (n.d.b). [_Workflow assessment for health IT toolkit_Links to an external site.](https://digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit). Retrieved January 26, 2022, from https://digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit

November 5, 2026
[Solved] Policy/Regulation Fact Sheet

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As a professional nurse, you are expected to apply your expertise to patient care. On occasion, you will also be expected to share that expertise. With evolving technology and continuous changes to regulations designed to keep up these changes, there is usually a need to share information and expert…

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As a professional nurse, you are expected to apply your expertise to patient care. On occasion, you will also be expected to share that expertise.
With evolving technology and continuous changes to regulations designed to keep up these changes, there is usually a need to share information and expertise to inform colleagues, leadership, patients, and other stakeholders.
In this Assignment, you will study a recent nursing informatics-related healthcare policy, and you will share the relevant details via a fact sheet designed to inform and educate.
**To Prepare:**
– Review the Resources on healthcare policy and regulatory/legislative topics related to health and nursing informatics.
– Consider the role of the nurse informaticist in relation to a healthcare organization’s compliance with various policies and regulations, such as the Medicare Access and CHIP Reauthorization Act (MACRA).
– Research and select one health or nursing informatics policy (within the past 5 years) or regulation for further study.
**The Assignment: (1 page not including the title and reference page)**
Create a 1-page fact sheet that your healthcare organization could hypothetically use to explain the health or nursing informatics policy/regulation you selected. Your fact sheet should address the following:
– Briefly and generally explain the policy or regulation you selected.
– Address the impact of the policy or regulation you selected on system implementation.
– Address the impact of the policy or regulation you selected on clinical care, patient/provider interactions, and workflow.
– Highlight organizational policies and procedures that are/will be in place at your healthcare organization to address the policy or regulation you selected. Be specific.
– Use APA format and include a title page, in-text citations, and reference page.
– Use the Turnitin Drafts to check your match percentage before submitting your work.
Weekly Resources
McGonigle, D., & Mastrian, K. G. (2022). _Nursing informatics and the foundation of knowledge_ (5th ed.). Jones & Bartlett Learning.
– Chapter 8, “Legislative Aspects of Nursing Informatics: HIPAA, HITECH and Beyond” (pp. 161–181)
– American Association of Nurse Practitioners. (2018). [_MACRA/MIPS: The transition from fee-for-service to quality-based reimbursement_Links to an external site.](https://www.aanp.org/legislation-regulation/federal-legislation/macra-s-quality-payment-program). Retrieved from https://www.aanp.org/legislation-regulation/federal-legislation/macra-s-quality-payment-program
– Centers for Medicare and Medicaid Services. (n.d.). [_MACRA_Links to an external site.](https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html). Retrieved January 18, 2019, from https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html
– HealthIT.gov. (2018a). [_Health IT legislation_Links to an external site.](https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation). Retrieved from [https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislationLinks to an external site.](https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation)
– HealthIT.gov. (2018b). [_Meaningful use and MACRA_Links to an external site.](https://www.healthit.gov/topic/meaningful-use-and-macra/meaningful-use-and-macra). Retrieved from
https://www.healthit.gov/topic/meaningful-use-and-macra/meaningful-use-and-macra
– U.S. Department of Health and Human Services. (n.d.). [_Laws & Regulations_Links to an external site.](https://www.hhs.gov/regulations/index.html). Retrieved September 27, 2018, from https://www.hhs.gov/regulations/index.html
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Rubric11.pdf](https://www.sweetstudy.com/files/rubric11-pdf-10364413 "Rubric11.pdf")

November 5, 2026
[Solved] mod 5 507

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November 5, 2026
[Solved] Discussion

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November 5, 2026