5220 Advanced Health Assessment Mixed up Subjective and Objective Data Work Sheet A.J. is a 15-year-old female who is presenting to your primary clinic setting with her mother.  A.J. is a new patient, and this is her initial visit.  Her complaint is “left leg pain.” MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

5220 Advanced Health Assessment Mixed up Subjective and Objective Data Work Sheet A.J. is a 15-year-old female who is presenting to your primary clinic setting with her mother.  A.J. is a new patient, and this is her initial visit.  Her complaint is “left leg pain.” MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

 5220 Advanced Health Assessment

Mixed up Subjective and Objective Data Work Sheet

A.J. is a 15-year-old female who is presenting to your primary clinic setting with her mother.  A.J. is a new patient, and this is her initial visit.  Her complaint is “left leg pain.” MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

Vitals:    Temp:  37.0 C

HR: 88

RR: 16

BP: 110/72

Height: 5’ 6.”

Weight: 70.5 kg

    
 	
  1. Read the rest of the case study below and then complete the blank Soap Note attached to the scenario.  Use only the information provided.

      
 	
    1. Decide what is pertinent and then place the components in the correct sections of subjective and objective components
      2. 
 	
    2. Use appropriate abbreviations and concise terminology if appropriate
      3. 

    

    2. 
 	
  2. Provide a second Word document answering the following questions

      
 	
    1. What type of history will you obtain for this visit? MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment
      2. 
 	
    2. What additional history would you obtain from the family that is significant to A.J.’s situation
      3. 
 	
    3. Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided
      4. 
 	
    4. For each of the following

        
 	
      1. Medical Diagnosis, 2 primary

          
 	
        1. Provide pathophysiology/Rationale/Plan
          2. 
 	
        2. ICD 10 code
          3. 

        

        2. 
 	
      2. Differential diagnosis, 3-5 Differentials

          
 	
        1. Provide pathophysiology/Rationale/plan
          2. 
 	
        2. ICD 10 code
          3. 

        

        3. 

      

      5. 

    

    3. 



    
 	
  • Health maintenance/risk profile
    • 



    
 	
  1. Pertinent positives
    2. 
 	
  2. Pertinent negatives
    3. 



    
 	
  1. Reference list
    2. 
 	
  2. APA format
    3.

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