Using the South University Online Library or the Internet, research the tympanic membrane and the thyroid gland. Based on your findings, create a 5- to 6-page Microsoft Word document that includes:
Support your responses with examples.
On a separate references page, cite all sources using APA format.
SOAP documentation is a problem-oriented technique whereby the nurse identifies and lists the patient’s health concerns. It is commonly used in primary health-care settings. Documentation is generally organized according to the following headings: S = subjective data Example: What is the patient experiencing or feeling, how long has this been an issue, what is the frequency, intensity, duration, what makes it worse or better, any past history, family history, home monitoring results (BP, weight, glucose monitoring), etc. O = objective data Example: Results of the physical exam, relevant vital signs, what the nurse observes, etc. A = assessment Example: What is the nursing diagnosis or medical diagnosis (for existing problems), identification of the problem, etc. P = plan Example: What interventions are done during the visit, what is the follow-up, what medications have been prescribed or changed, what further testing or investigations are required, when will the patient be seen again, etc. Sample chart note: S: In for refills and review of diabetes. Home glucose monitoring – taking BG readings 3 times/week in morning only (fasting). Average BG 7-8. Has been trying to avoid sugary snacks but has just quit smoking so is finding this difficult. Walking 5 times/week for 30 minutes. O: Blood work – A1C 7.2 (was 7.3), LDL 1.9, Ratio 3. BP 118/70. HR 72 regular. A: Diabetes (A1C not at target) P: Provided with information on A1C, diabetes and targets. Provided with support and information related to nutrition and strategies to reduce sugary snacks. Reviewed blood glucose testing and will check postprandial sugars 2/week until next visit.
1. Encouraged to book eye exam 2. Due for foot exam next visit 3. Increase metformin to 1000mg bid 4. Repeat BW in 3/12 (annual inc nephropathy screening) – encouraged to check
glucometer with bloodwork 5. RTC 3/12
by Dalianis Diaz
Submission date: 29-May-2019 08:55PM (UTC-0400) Submission ID: 1137627730 File name: TympanicMembraneAndThyroidGland.docx (28.86K) Word count: 1900 Character count: 10006
No SOAP review for tympanic membrane. Health histories and SOAP notes to be patient specific as in the hospital and as described.
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TympanicMembraneAndThyroidGland.docx ORIGINALITY REPORT
Submitted to EDMC Student Paper
Submitted to Mesa State College Student Paper
Submitted to South University Student Paper
Submitted to Abingdon and Witney College Student Paper
Submitted to Weston College Student Paper
www.quantabio.com Internet Source
research-repository.uwa.edu.au Internet Source
Submitted to University of Keele Student Paper
academic.oup.com Internet Source
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Exclude quotes Of f
Exclude bibliography Of f
Exclude matches Of f
www.tnuniv.ac.in Internet Source
David S. Sharlin. "Chapter 9 Disruption of Auditory Function by Thyroid Hormone Receptor Mutations", Springer Nature, 2016 Publicat ion
Submitted to Borders College Student Paper
140/160 TympanicMembraneAndThyroidGland.docx GRADEMARK REPORT
Text Comment. h
Text Comment. No SOAP review f or tympanic membrane. Health histories and SOAP notes to be patient specif ic as in the hospital and as described.
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