HEENT soap note

• SOAP Note:
  • A full SOAP Note is required for the HEENT (head, ears, eyes, nose, and throat assessment)
  • For those videos, the student will decide on the Chief Complaint (CC) which must be appropriate for the associated body system (no ER or ICU type CCs).
  • The student will complete all SOAP components
  • The Subjective section includes the following: ID (Initials, Age, DOB, Sex, Race, Accompanied, and Historian), CC, HPI (using OLDCARTS for problem-focused history), PMH, Family History (as pertinent), Social History (as pertinent), and ROS (problem-focused based on body system).
  • The Objective section includes: expected vital signs and the physical examination documentation with detailed focus on the weeks body system (as well as general, and basic assessment of CV and Pulmonary).
  • The Assessment section must contain 3 differential diagnoses with rationale and in-text citations to credit the evidence-based sources used to defend the diagnosis choices. One of these three diagnoses must be the final or working diagnosis.
  • The Plan section is based on the working/ final diagnosis. This must include the five aspects of a plan which are diagnostics, treatments, education, referral (if applicable), and follow-up. The student should use in-text citations to credit their sources of information for each aspect of the plan.
  • The student must use a minimum of 5 references which should be recent (within last 5, but up to 10 years if clinical practice guideline) and should be peer-reviewed.
  • Use APA title page, citations, and reference format
  • Patient: 18 year old white (DOB: 08-12-2008), Caucasian female complains of sinus pressure and clear nasal drainage for the past 4 days. Primary Diagnosis- Allergic Rhinitis.
  • Make up a scenario for a fake patient to have Allergic rhinitis, include vital signs, differential diagnosis, history of present illness (HPI). Include at least 5 scholarly sources overall from scholarly articles within 2021-2026. I included an example paper and the rubric.

  	Competent	Below Standard	Far Below Standard	Criterion Score
  Subjective: ID, CC, HPI, PMH/SH|, ROS	All pieces present and adequately documented. The HPI and ROS was pertinent to the complaint. PMH was clear and pertinent to the complaint. Information was clear and concise, not superfluous.	Most pieces adequately documented. The HPI and ROS were mostly pertinent to the complaint. Information was mostly clear, with only slight amount of info. Missing or too much information included.	Missing part of the subjective component, or done incorrectly. HPI missed some of the OLDCART elements. ROS was confused with physical exam or was not pertinent to complaint. PMH missing half or more elements.	Severe deficits in subjective information. Very limited or no HPI or very limited or no ROS. Past medical history missing key elements.	/ 8
  Objective: VS & PE	Student wrote VS and physical exam findings in an organized, thorough, and succinct summary. Physical exam for the particular weeks body system was elaborated upon. Student included only pertinent systems besides the weekly focus exam.	Student wrote VS and physical exam findings in an organized, thorough, and succinct summary. Physical exam for the particular weeks body system was lacking detail. Student included either too little information on other systems, or performed too many systems, similar to well or annual exam.	Physical exam findings were disorganized and difficult to read. The particular body system for weekly focused was inadequately described or missing. Student did not include other body systems that were pertinent to the complaint.	Severe deficits in documentation of the physical exam findings. Student did include other systems besides weekly system in the write-up.	/ 7
  Assessment with DDX and Plan	DDX contained at least 3 different, pertinent diagnoses considered for the scenario. Student briefly listed why diagnoses were excluded Final assessment/ Dx was clear, and reasonable (might not be 100% correct). Plan included all elements listed, and reasonable for a beginner practitioner, even if not 100% correct.	DDX contained at least 3 different, pertinent diagnoses considered for the scenario, but student did not include why dx were ruled out. Final assessment/ Dx clear, even if not correct. Plan includes most elements listed, even if not all correct.	DDX was limited or not included. No rationale for why dx was excluded. The plan was missing elements or was not in line with the chief complaint and physical findings.	The assessment and plan was missing or lacking major components. Lacked a DDX and the plan was missing major elements.	/ 10
  Format/Grammar/Spelling	The chosen format was neat and easy to read. Headings were clear. APA format was correct.	The format was mostly easy to read and understand, some elements of APA format is missing.	The format was inconsistent, headings and different areas were not delineated. No APA format.	Very poor format, note was confusing to read, no APA format.	/ 5

  Total

  / 101

Struggling with your essay and deadlines?

Get this or a similar paper done in as fast as 4 hours, 24/7.

NB: We do not sell prewritten papers. All essays are written from scratch according to specific needs and instructions

✔Secure Service ✔ Plagiarism Free ✔On-time Delivery

WRITE MY PAPER