NSG 6020 Week 7 iHuman Soap Note – Breast Cancer Examination
NSG 6020 Week7 iHuman Soap Note – Breast Cancer Examination
Week 7 SOAP Note Assignment
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned. NSG 6020 Course Discussion Assignment Papers.
SOAP NOTE
Name: C.C
Date: May 23, 2018
Time: 1600
Age: 41
Sex: Female
SUBJECTIVE
CC:
“I am here for my wellness check and have questions about breast cancer risks. My mother and first cousin on my mom’s side was just diagnosed with breast cancer.”
HPI:
Patient came in today for a well-woman examination. She has no active medical complaints, but is concerned about her risk of breast cancer as both her mother and maternal first cousin have been recently diagnosed with breast cancer.
Medications:
none; Ibuprophen for headaches
PMH: None
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Chronic Health Problems: None
Hospitalizations/Surgeries:
Bilateral tubal ligation after her last delivery at age 35; SVD x 2
NSG 6020 Week7 iHuman Soap Note – Breast Cancer Examination
Other:
Immunizations: Flu and TDAP up-to-date
Environmental Hazards:
Patient denies any environmental hazards. Patient lives in a single story clean home with her husband and 2 kids. She is able to perform her ADLs.
Safety Measures:
Patient states she uses safety precautions
Exercise and leisure:
Patient states she is pretty active with her husband and kids. Every weekend she states that she is in the garden. Patient stated that she walks to the train 5 days a week.
Sleep:
Patient states “We usually lay down around 2100 each night and usually get to sleep around 2200 and wake up around 0530. Reports that she feels rested after sleeping. Takes a nap on the weekends for about an hour and a half.
Diet:
Patient states that she eats a well-balanced diet. Drinks a smoothie in the morning for breakfast. Drinks about 2.5 liters of water per day. 24HR recall: Breakfast: Berry smoothie, Lunch-chicken salad wrap on tomato basil wrap. Dinner-Sautéed Salmon with seasoned broccoli with 1 glass of wine.
Family History:
Mrs. C.C’s parents are alive. Her father has hypertension and hyperlipidemia. Her mother has type 2 diabetes and new diagnosis of breast cancer. No sisters and she has brothers that are pretty healthy and active.
Week 8 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided
Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
Week 9 SOAP Note Assignment
SOAP NOTE
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided. NSG 6020 Course Discussion Assignment Papers.
Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.