NRP/531: Advanced Health Assessment I

Assignment Content

1. 
   
   This week you have gained insight about how to properly examine and document findings for the spine, shoulders, elbows, hands, wrists, fingers, hips, knees, feet and ankles, including specialty tests. You learned the importance of assessing range of motion and muscle strength, along with properly executing specialty exams to further assess joint stability all to narrow your list of potential diagnoses.
   Now it is time to apply your documentation skills by writing an episodic SOAP note for Mr. Tom Walker who presents to you with multiple complaints.
   Review the Tom Walker Scenario.
   Use the SOAP Note Template and the SOAP Note Structure Guide to develop your documentation needed to complete your SOAP Note.
   The assessment and plan sections will not be graded but should be completed to ensure documentation of a complete SOAP Note. You will also use this information to complete your E&M coding for the visit. Make sure to:

   • Document all relevant information using appropriate terminology.
   • List the appropriate ICD-10 codes and E&M codes using the diagnoses provided.