Nursing & Medical diagnosis/es formulated with correct ICD- 10 codes. Include health maintenance diagnosis per guidelines. You MUST provide at least 3 likely differential diagnoses and list R/Os if appropriate.
Include pertinent positives & negatives for the Mgt plan cost-effective, clinically correct & includes sections for medical & nursing therapeutics. Patient education should be identified as such. Organize categories in your plan: Diagnostic, Therapeutic, Pt Education, Referral, & Follow-Up. major diagnosis only.
Attach a current clinical guideline with clear reference for one of the major diagnoses. Rationale justifies EACH ASPECT of mgt plan with appropriate references. Mechanism of action of medications you change/prescribe should be cited here .
Pathophysiology discussion justifies major diagnoses addressed at visit and mgt plan. 1) You must personalize to your patient’s health status by discussing how it applies specifically to your patient. 2) No more than 2 diagnoses need to be addressed if multiple dx exist. 3) Use a CURRENT primary patho reference 4) Do not duplicate pathophysiology from prior SOAPs Health Promotion/Prevention. Include age/gender/risk specific
Recommendations as your guidelines require.