Download and analyze the case study. Create a SOAP (SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN) note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information
Use this website for ICD-10: https://www.cms.gov/medicare-coverage-database/search.aspx?error=Please%20use%20the%20new%20MCD%20Search%20to%20find%20documents%20with%20ICD-10%20codes.
Format
Put the cheif complaint in quotation mark
Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem.
Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.
care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Paper should be no longer than 3-4 pages excluding the title and the references and in 12pt font.
