CREATE THE SOP NOTE USING THE GUIDE AND PATIENT INFORMATION

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<p><font color=”#FFFFFF” size=”2″>&nbsp; <b>Miami Regional University&nbsp;&nbsp; </b>(Acct #3111)</font></td>
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<td width=”50%”><b><font size=”2″>&nbsp; Case ID #: 2844-20220119-004</b></font><font size=”2″>
&nbsp;&nbsp;(Status:&nbsp;NOT Approved)
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<p align=”right”><b><font size=”2″>Date of Service:
1/19/2022&nbsp;</font></b><font size=”2″></b></font></font></font></td>
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<p align=”center”><font color=”#FFFFFF” size=”2″><b>Student Information – Santiesteban Molina, Osmel</b></font></td>
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<p align=”right”><font size=”2″><b>Semester:</b></font></td>
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Spring
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<font size=”2″><b>Course:</b></font></td>
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MSN6150C Advanced Practice Pediatrics
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<b><font size=”2″>Preceptor: </font></b></td>
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TREJO, RODOLFO
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<b><font size=”2″>Clinical Site</font></b><font size=”2″><b>:</b></font></td>
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Neighborhood Family Doctor.Atlantis
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Setting Type</font></b><font size=”2″

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: ___________________

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C

Soap Note

PATIENT INFORMATION

Name: Mrs

Age: 32 years old

Gender at Birth: Female

Gender Identity: Female

Source: Patient

Allergies: NKDA

Subjective Data

Chief Complaint (CC)

The affected person communicates issues approximately her right eye. She reviews having a tingling and eating sensation in his proper eye. Also, She says that the attention creates greater fluid than expected, and the affected person frequently awakens with a dried up eyelid.

History of Present Illness (HPI)

The affected person is femmale. She is 32 years of age. The affected person wears touch focal factors because of having nearsightedness. Nonetheless, there may be no acknowledged records of her having a few different illnesses related to eyesight problems. The precept grievances of the affected person comprise redness and inflammation of the conjunctiva of the proper eye, accelerated tear advent and presence of fluid launch in the attention. Besides, she reviews to having problems with carrying his touch focal factors. The proper eye started out to tingle and eat 3 days prior. The affected person tried to smooth the attention with water and searched for any unexpected articles which could have brought about the bothering. Then, at that point, the affected person carried out Visine eye drops, which in brief mitigated the aggravation. Be that because it may, the redness did not disappear. The left eye seems to appearance sound. The affected person reviews to having notable cleanliness and says that she washes palms mechanically.

Allergies

NKDA

Past Medical History

The affected person became decided to have nearsightedness while he became twelve years of age. She normally wore glasses. Nonetheless, she selected to extrude to touch focal factors a month prior. The affected person has no set of reviews of various illnesses related to eyesight. No beyond records of eye illnesses is recorded.

Family History

The affected person denies having any own circle of relative’s ancestry pertinent to his condition. The dad has a beyond packed with controlled high blood pressure. She takes meds and plays mechanically check-u.s. the clinical clinic. The mom has a historical past marked via way of means of a summed up anxiety problem, that’s being dealt with treatment. She became decided to have GAD a 12 months prior. No scientific records recognized with eye infections may be found.

Surgery

The affected person has no set of