Telehealth Focused SOAP Note Assessment Assignment
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Week 15 Case Study Scenario
Telehealth has become a norm for patient communication since the COVID-19 pandemic started.A scheduled time for a virtual telehealth OSCE visit has been completed with the below information from the notes of the virtual telehealth OSCE visit. During the virtual OSCE Telehealth visit you role played with your instructor as the part of a FNP-S (Family Nurse Practitioner Student) who is seeing a patient (played by your faculty instructor) with a common complaint via telehealth. As the FNP-S provider, you must ensure the following:
Â Your patient (faculty instructor) has provided you with the case study scenario (see below)Telehealth Focused SOAP Note Assessment Assignment.
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J. S. is a 25-year-old (DOB 05/27/1997) female who presents as a new patient with sore throat for a virtual telehealth visit today. You will be doing the visit as a FNP-S (Family Nurse Practitioner Student). You will need to complete a â€œFocused SOAP Note for a new patientâ€ for this virtual telehealth visit (see attached SOAP note template). This will need to include a detailed history since she is a new patient. You MUST use the attached SOAP note template for this assignment in 7th edition APA format. Her CC (chief complaint) is a sore throat that is worse upon waking up the last couple of days w/ some head and sinus congestion, sneezing, clear sinus drainage, watery eyes (rhinorrhea), and afebrile. She reports her throat feels like something is in it and she needs to clear her throat often. In the past she has taken Loratadine (Claritin) 10mg daily PRN for seasonal allergies but not recently. She lives with her boyfriend off campus, attends college full time, and works full time as a waitress. c/o of difficulty sleeping and focusing on homework with the congestion and sore throat. She is unable to breathe through her nasal passages at times due to the increased congestion and breathes through her mouth. She reports her mouth is very dry. NKDA & NKFA. Home medications are MVI daily. Ibuprofen 200mg PRN headache. She had visible allergic â€œshinersâ€ dark circles under her eyes.
Â Develop and complete a SOAP note (focused new patient) using the SOAP note template provided. Include the following: The relevant subjective information including the identifying data, chief complaint history of present illness, and review of systems patientâ€s age and developmental status. The relevant objective data including vital signs, physical exam findings, lab/imaging results, and other diagnostic data. Note that includes subjective assessment, a brief objective assessment (as applicable for telehealth), and a full treatment plan including your patientâ€s diagnosis, prescription, and non-prescription treatment recommendations, and follow up plan. A detailed treatment plan including the patient plan and education diagnostic/screening orders, prescriptions with doses and patient instructions, and a follow-up plan that is appropriate for the patientâ€s age and developmental status. Telehealth Focused SOAP Note Assessment Assignment
Â Identify the appropriate ICD 10 and E&M Codes for this telehealth visit (see attached guide for E&M codes).
Â An assessment that includes your diagnosis(es) and top 3 differential diagnoses you considered
Â Following the visit, you provided your instructor (faculty) with a full patient report/case presentation of the telehealth visit. Feedback was be provided. Determined PRIMARY Diagnosis is Allergic Rhinitis (AR) ICD10. The following differential diagnosis were determined: 1. Strep throat group A, 2. GERD, 3. Common head cold, Influenza, COVID-19 (all 3 are VIRAL). You need to include and cite all diagnosis and treatment recommendations on SOAP note including on the reference page at end of assignment. All in 7th edition APA format.
Â Following the visit, your instructor and you determined the following prescriptions were written for patient: Loratadine (Claritin) 10mg PO daily for 14 days. Fluticason (Flonase) nasal spray 1 squirt in each nostril twice daily for 14 days.
Â FNP-S will do a follow up call with patient in 24-48 hours to ensure patient symptoms are not worsening.
Â Use the SOAP Note template attached with assignment instructions. Remember, this is a focused SOAP note, so all fields may not apply.
Â Include a reference page in 7th edition APA format with a minimum of three scholarly peer reviewed. Textbooks do NOT qualify as scholarly peer reviewed references.
Â Cite all references according to 7th edition APA guidelines.
Â Write paper in 7th edition APA format, including reference page. Telehealth Focused SOAP Note Assessment Assignment
Fitzgerald,â€¯M.â€¯A.â€¯(2021). Nurse practitioner certification exam prep (6thâ€¯ed.).â€¯â€¯F.â€¯A.â€¯Davis.
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care: The art and science of advanced practice – An interprofessional approach (5th ed.). F. A. Davis.
David, J. A. (2020). Current practice guidelines in primary care 2021-2022. McGraw-Hill Companies, Inc. Telehealth Focused SOAP Note Assessment Assignment
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