would ask using descriptive language familiar H e a l t h M e d i c a l

would ask using descriptive language familiar H e a l t h M e d i c a l

Part 1 SOAP This week you have gained insight about the pediatric assessment, as you have compared the head to toe examination of the infant, child, and adult.

Now it is time to apply your documentation skills by writing a comprehensive SOAP note focused on a 7-year-old well child check with parental concerns of short stature.

Review the BP case scenario above.

Use the SOAP Note Template and the SOAP Note Structure Guide to develop your documentation needed to complete your SOAP note. Make sure to review the The 10 charts in Set 2: Clinical charts with 3rd and 97th percentiles from the National Center for Health Statistics and reference the appropriate chart within the SOAP note.

The assessment and plan sections will not be graded but should be completed to ensure documentation of a complete SOAP note. You will also use this information to complete your E&M coding for the visit. Make sure to:

  • Document all relevant information using appropriate terminology.
  • List the appropriate ICD-10 codes and E&M codes using the diagnoses provided.

Part II Reflection

Assignment Content

  1. Now that you have completed your SOAP note for B.P., it is time for reflection. This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives. Write a 700-word reflection providing rationale for your completed SOAP note. Consider the interview information provided in the patient scenario as you:

    • List 5 open-ended questions you would ask using descriptive language familiar to the patient during the HPI exam relevant to the chief complaint, including all pertinent and positive negatives. Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint.
    • Provide a minimum of 3 rationales for the physical exam components performed.
    • Locate and review a current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis. Provide a brief summary of the article(s) in your reflection.
    • Identify a minimum of 2 barriers to quality health care the patient can potentially experience per the information provided in the interview (e.g., cultural, linguistic, economic, previous conditions, etc.).
    • As the FNP, explain how you can address these barriers to improve the quality of care the patient receives. Use a minimum of 2 peer reviewed articles to support your answers.

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