Fill out template as directed.

Dont forget to do the SOAP Note. Follow Format below for the soap note..

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Demographic Data

• Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC) unless an Annual Physical Exam (APE)
• History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
• Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable

• Family Hx: As applicable
• Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

• Vital signs

• Physical findings listed by body systems, not paragraph form

Assessment (Diagnosis/ICD10 Code)

• Include all diagnoses that apply for this visit

Plan

• Dx Plan (lab, x-ray)

• Tx Plan: (meds)
• Pt. Education, including specific medication teaching points
• Referral/Follow-up
• Health maintenance (including when screenings, immunizations, etc., are next due):

The diagnosis should appear on one line in the following order.
Note: Do not include the plus sign in your diagnosis. Instead, write the indicated items next to each other.

Code + Name + Specifier (appears on its own first line)
Z code (appears on its own line next with its name written next to the code)

Then, respond to the following:

• Explain how you support the diagnosis by specifically identifying the criteria from the case study.

Describe in detail how the client’s symptoms match up with the specific diagnostic criteria for all the disorder that you finally selected for the client. Note: You do not need to repeat the diagnostic code in the discussion.

Identify the differential diagnosis you considered.

Explain why you excluded this diagnosis/diagnoses. 

Explain the specific factors of culture that are or may be relevant to the case and the diagnosis, which may include the cultural concepts of distress.

Explain why you chose the Z codes you have for this client.

Week 4 of Ethics for Healthcare Professionals.

Discussion 1:  Health care professionals are morally obligated to ensure their clinical decisions are informed and reflect best practices. The first step in ethical decision-making is to gather as much relevant information as possible. Describe the types of guidelines you would use to decide that you have as much information as you need to ensure an ethical decision. In replies to peers, discuss under what conditions, if any, you might decide not to act according to your own moral obligations. Provide an example to justify your response.
 

Discussion 2: In any professional career one should prefer to act ethically. Explain types of reflective practices and methods and how to integrate them into your work life to ensure that you think critically about both the art and the science of your patient care delivery. Provide examples. In replies to peers, describe what it means to act ethically in your professional career.