Explain the plan that you are suggesting or that was done, including any education, further work-up, specific medications with doses and frequency, consultations/referral, and follow-up

Learning Goal: I’m working on a nursing discussion question and need an explanation and answer to help me learn.

Please write SOAP note about a 29 year old female pt that comes to clinic for asthma management.

Please write APA 7th edition and use 3 references.

Documentation SOAP Note

Create a focused exam SOAP note based on a case during your clinicals. This same case will be used for your Unit 6 presentation video. References should be guidelines that support the treatment plan and related condition/s.

Subjective

• Opener presentation of the patient (age/sex/presentation of issue with key past DX)
• History of present illness (HPI) (OldCarts)
• Other related past medical history
• Review of systems (ROS)

Objective

• Vital signs and physical exam on pertinent body systems

Assessment

• Assessment including differentials and specific labs or X-rays reviewed

Plan

• Explain the plan that you are suggesting or that was done, including any education, further work-up, specific medications with doses and frequency, consultations/referral, and follow-up