This section of the SOAP note will include history of lifestyle patterns and the review of systems (ROS).Document appropriate data in the relevant body system. Do not state “Negative, NA or Unrem

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This section of the SOAP note will include history of lifestyle patterns and the review of systems (ROS).

  1. Document appropriate data in the relevant body system.

    1. Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider.
  2. This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history.
  3. Address each component of the SOAP note as noted in the written guide with relevant data.
  4. You may continue with the same volunteer to complete each section of the SOAP note.
  5. Click here for the

    written guide

    for this Assignment. (Attached)

This section of the SOAP note will include history of lifestyle patterns and the review of systems (ROS).Document appropriate data in the relevant body system. Do not state “Negative, NA or Unrem
MN552 Advanced Health Assessment Unit 3 SOAP Note Section II and III Written Guide Document appropriate data in the relevant body system. Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider. This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history. Address each component of the SOAP note as noted in the written guide with relevant data. You may continue with the same volunteer to complete each section of the SOAP note. II. Life style patterns Immigrant status Spiritual resources/religion Health perception Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins Occupational health: Known exposure to environmental toxins at work Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook) Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family Cognitive function: Memory; speech; judgment; senses Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep Exercise patterns: Type and frequency Hobbies/recreation: Leisure activities; any travel outside of the US Social habits: Tobacco; alcohol; street drug use Intimate partner violence (review screening questions on page 58 in the Jarvis textbook) Coping/stress management: Any major life change in past 2 years; do you feel tense; source; what helps Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function III. Review of Symptoms Symptoms to Inquire About (please see page 54–56 in Jarvis textbook) Document pertinent negatives and/or positives The first system is addressed to provide a guide General Wgt Δ; weakness; fatigue; fevers Pertinent negatives: No weight gain or losses; no weaknesses, fatigue, or fevers Pertinent positives: Positive weight gain over past 2 months with fatigue and weakness; no fevers Skin Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails Head Headache; head injury; dizziness or vertigo Eyes Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma Ears Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use Nose/ Sinuses Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain Throat/ Mouth Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste Neck Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion Breasts Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area Pulmonary Cough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest x-ray, TB skin test Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance GU Frequency; nocturia; urgency; dysuria; hematuria; incontinence Females: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps; menopause; hot flashes; post-menopausal bleeding; Males: Caliber of urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often Peripheral Vascular Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers Musculo-skeletal Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease Neuro Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations Heme Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation Endo Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distribution Psych Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses
This section of the SOAP note will include history of lifestyle patterns and the review of systems (ROS).Document appropriate data in the relevant body system. Do not state “Negative, NA or Unrem
NR632 Nurse Executive Concluding Graduate Experience II Kickoff PowerPoint Presentation: Week 1 Guidelines and Scoring Rubric Purpose The kickoff-to-execution presentation is designed to get everyone on the right path while inspiring and motivating them to succeed. This is your opportunity to showcase the work you have done designing and planning your project as well as the unique tools you developed and are about to implement. Your kickoff PowerPoint presentation is the key to setting the tone for the kickoff meeting. If you have already conducted a formal kickoff and have started execution of your project, complete this as if you had not done so yet. Gather as many colleagues as possible to present your PPT. For actual kickoffs present your PPT to as many of the project teas as possible. Refer to the PowerPoint sample template in Course Resources. Due Date: Sunday 11:59 p.m. MT of Week 1. Total Points Possible: 100 Requirements Complete the Kickoff PowerPoint presentation. All slides must have speaker notes Grammar, spelling, punctuation, references, and citations are consistent with formal academic writing and APA format as expressed in the 6th edition. Preparing the paper You must recap your project plan, getting everyone in agreement for project, while you motivate and inspire your team and stakeholders. Introduce and give thanks to team members who have worked hard to get the project to the implementation phase. Give comments that help the teams realize that they are important. Discuss each team member’s role in project. Everyone in the room is important and vital to the project’s success. You must have at least 33 slides. It is important to note that if you could not give your presentation and someone would have to stand in for you, he or she would need to know what you were going to say. All slides must have speaker notes so that someone may step in for you. Maintain the 6x6x6 rule for a professional PowerPoint presentation. No more than 6 lines per slide, 6 words per line, and 6 slides without a graphic. Ideas and information from professional sources must be cited correctly, using the 6th edition of the APA manual. Grammar, spelling, punctuation, references, and citations are consistent with formal academic writing. Category Points % Description Kickoff PowerPoint Presentation 80 80 The plan is thoroughly reviewed, gets everyone on board by including all of the critical elements as included in the PowerPoint document provided; the presentation is inspiring and motivating: All slides have speaker notes Grammar, spelling, punctuation, references, citations, and APA formatting 20 20 Grammar, spelling, punctuation, references, and citations are consistent with formal academic writing and APA format as expressed in the 6th edition. Total  100 100 A quality assignment will meet or exceed all of the above requirements. Grading Rubric Assignment Criteria Exceptional (100%) Outstanding or highest level of performance Exceeds (88%) Very good or high level of performance Meets (80%) Competent or satisfactory level of performance Needs Improvement (38%) Poor or failing level of performance Developing (0) Unsatisfactory level of performance Content Possible Points = 80 Points Kickoff PowerPoint Presentation 80 Points 70 Points 64 Points 30 Points 0 Points The plan is thoroughly reviewed, getting everyone on board by including all of the critical elements as included in the PowerPoint, and the presentation is inspiring and motivating. It follows 6X6X6 rules; every slide includes notes The plan is lacking one or two critical elements included in the PowerPoint document to help get everyone on board, and the presentation is inspiring and motivating. It follows 6X6X6 rules; every slide includes speaker notes The plan is lacking three critical elements included in PowerPoint document to help get everyone on board, or the presentation is not inspiring and motivating. It does not follow 6X6X6 rules; missing speaker notes The plan is lacking four critical elements included in the s PowerPoint to help get everyone on board, or the presentation is not inspiring and motivating. . It does not follow 6X6X6 rules; missing speaker notes The plan is lacking five or more critical elements included in the PowerPoint to help get everyone on board, or the presentation is not inspiring and motivating or is text heavy without notes in the notes section. Content Subtotal _____of 80 points Format Possible Points = 20 Points Grammar, spelling, punctuation, references, citations, and APA formatting 20 Points 18 Points 16 Points 8 Points 0 Points No grammar, spelling, punctuation, references, citation, or APA errors 1 total grammar, spelling, punctuation, references, citation, or APA error 2 total grammar, spelling, punctuation, references, citation, or APA errors 3 total grammar, spelling, punctuation, references, citation, or APA errors 4 or more total grammar, spelling, punctuation, reference, citation, or APA errors Content Subtotal _____of 20 points Total Points _____of 100 points

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