health care charting nursing school
Posted by:admin | May 22, 2021
This assignment has 3 parts to it:
Write a 1000-word essay summarizing each of the two different charts below, how they will be used in your chosen career, proposed improvements and better ways this information could be conveyed. Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. Support your ideas with at least one (1) citation in your essay. Make sure to reference the citations using the APA writing style for the essay. The cover page and reference page do not count towards the minimum word amount. Review the rubric criteria for this assignment.
Your assignment is to include the list below and put the items in a SOAP format. You will want to research to find a form of your choice. You may add words to make sentences out of some of these items. When you get done, you should be able to view the notes and have a picture of this patient and know the next steps. Make sure that you have the needed information from your research of SOAP notes.
John Smith, DOB 08-10-1951 came into the clinic to see Dr. Jerry Jones. Below are notes taken during Mr. Smiths visit.
Blood Pressure: 165/85
Patient complains of left arm pain.
Complains of leg weakness and increases with going up steps
Diagnosis: Hypertension, bilateral edema legs, and ankles, Heart Disease, Diabetes
Elevate legs for 1 hour 4 times a day
Height: 182 cm
Inflammation on both lower legs
Pain is aching
Pain is better when I elevate my legs
Pain is worse at night
Peripheral edema, both ankles
Prescribe Hydrochlorothiazide, 25 mg tablet, 1 per day in the am.
Pulse Oximetry: 97%
Pulse: 60 bpm
Rate pain 5 out of 10
Respiration: 16 bpm
Return for follow-up in two weeks
Wear support stockings till next appointment
Weight: 165 kg
X-rays show no fractures
PIE Charting Assignment
Review the bottom of page 160 of your text for patient charting using the PIE method. Using your creative mind, create a problem, provide interventions, and identify the results (evaluation). Your problem should include a paragraph (min 100 words), interventions (at least two min 100 words) and evaluation is a paragraph (min 100 words).
Assignment ExpectationsLength: 1000-word essay plus each of the charts.Structure: Submit the appropriate format for each item. Include a title page and reference page in APA style. These do not count towards the minimal word amount for this assignment.References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. Include at least one (1) scholarly citation to support your claims.Format: Save your assignment as a Microsoft Word document (.doc or .docx).
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