ADULT  Wellness check up 

Follow the Soap Note Rubric, template and directions attached  as a guide 

Use APA format and must include a minimum of 3 Scholarly Citations.

Will be placed through TURN-It-In (anti-Plagiarism program) and less than 15 % or will not be accepted 

Use the sample templates , and follow the directions and requests in the sample template . it must be 100 % complete and professionally done.

due 4 days. MInim0 1000 words.

History & Physical Format


IDENTIFICATION:

Date: 24/09/2021 Time: 10:00 am

Name: M.N Sex: F Race: Hispanic

Marital status: Divorced

Address: Los Angeles, CA.

Tel. 213-509-6995

DOB: 05/11/1985


SUBJECTIVE:

CHIEF COMPLAINT (CC): Annual Wellness Checkup

HISTORY OF PRESENT ILLNESS (HPI): The patient is a 36-year-old female who states that it has been a while since she came for a wellness check-up. She gave birth two years ago and had gestational hypertension. She says she was fine until recently she has been having some symptoms that she does not understand. Over the past two months, she had traveled to Mexico.

The patient complained about mild headaches that are accompanied by pain in the eyes, blurred vision at times, burning eyes, and itching sometimes. The patient has been having those symptoms for a one and half weeks now.

The patient also complains of lower abdominal pains and changes in stool from time to time. The pain is not frequent and come from time to time. Sometimes, the pain is so severe that she has to lay down and take pain medications for her to feel relieved. The abdominal pains have lasted for a month.

PAST MEDICAL HISTORY (PMH): The patient had gestational hypertension during her second pregnancy which had her having a cesarean section. No other complications have been noted.

FAMILY HISTORY (FH): The patient’s mother died 5 years ago of breast cancer. Her father is old and has osteoporosis and is in a care facility. Both of her children are healthy.

SOCIAL HISTORY (SH): The patient drinks alcohol occasionally, does not smoke.

REVIEW OF SYSTEMS (ROS): The patient has red eyes sometimes which are itchy. No history of eye disorders. The patient has changed vision with pain, and frequent headaches. The patient has difficulties with sleep sometimes. The patient has soft stools with blood and mucus occasionally, excessive gas, and rectal pain during bowel movement.

ALLERGIES: No known allergies.

MEDICATIONS: Ibuprofen, Loperamide and Tetrahydrozoline

HEALTH MAINTENANCE: The patient has been healthy, and actively involved in outdoor activities such as playing tennis, hiking, and traveling. The hydrates often go for massages and attend disease prevention conferences. The patient is intelligent and seems to be well informed about basic health issues. She likes to be relaxed and goes for yoga on Saturdays.


OBJECTIVE:

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________

School name and adress and LOGO here HEader

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

·

PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:


Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …


Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:


Objective Data:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:


ASSESSMENT:


(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)


Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3)


PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (