Please fallow instruction. I need you to make up a soap note for a male patientome currentlly leaving in a nursing h with diagnoses of COPD.
APA format with references at least no older than 5 years.
The Diagnosis and the 3 differential diagnoses with ICD 10 code.
I include the soap note template, the rubric to follow in separate attachments.
Complete Chief patient complent
Subjective Information
PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.
Complete Objective Information
Complete physical exam with critical elements related to subjective data.
Perform Assessment
Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Create a Plan
Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.
Self-Assessment & Clinical Guidelines
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.
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