DM2

Please see attached SOAP Noted document.I started making the SOAP note but I am running out of time to complete it.I just need somebody to complete the Diagnosis, differential diagnosis as well as the Plan and reflection.My patient is an 80 y.o woman who doesn’t speak English so there was a communication barrier and it was hard to ask history in patient’s like that.She was accompanied by her daughter who thinks everything was okay with her mother and that she was only in the office to refill medications and do her annual physical exam.

Please write 3 pages on Assessment, Plan and Reflection

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Assignment 1: Developing a Focused SOAP Note

 

To prepare:

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  • Review this week’s Learning Resources, including the Focused SOAP Note Template.
  • Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:( I STARTED THE SOAP NOATE)
    • Subjective: What details did the patient provide regarding his or her personal and medical history?
    • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
    •  
  • ASSIGNMENT STARTS HERE with assessment( I have diagnoses) all the way down to reflection.
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
  • Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Resources:

Please use minimum of three resources.Thank you!

 

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