Sentences – charting and documentation

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Sentences – charting and documentation

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4     Double-spaced (1200 words)

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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. SOAP Charting 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. Smith’s 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 Temperature: 98.5 Wear support stockings till next appointment Weight: 165 kg X-rays show no fractures PIE Charting Assignment 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).

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