Ken Fowler iHuman soap note

 To prepare:

Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with GI or GU conditions. 
Access i-Human from this week’s Learning Resources and review this week’s i-Human case study. Based on the provided patient information, think about the health history you would need to collect from the patient. 
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. Reflect on how the results would be used to make a diagnosis. 
Identify three to five possible conditions that may be considered in a differential diagnosis for the patient. 
Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis. 
Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with GI or GU conditions. 
Assignment
As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.

Patient Information:

Subjective:

CC (chief complaint):

HPI:

Current meds:

Allergies:

Vaccinations: 

Pertinent PMHx:

Social hx:

Fam Hx:

Questions: Copy the questions you asked in ihuman here

ROS:

Physical Exam:

Test ordered and diagnostic results:

List the differential diagnosis you identified in ihuman 

List your primary dx with ICD code. Briefly explain/ discuss your primary dx and the rational

List the differential Dx with ICD and a brief explanation the rational

Assessment/Plan:

Admit to: (ICU, Observation, med surge, etc)

Status: (critical ill, stable, guarded) 

CODE Status:

ALLERGY: 

Diet:

Activity:

Consult/ specialty services and rational:

Nursing orders: (iv, monitor, i/o etc..)
Medication/intervention: dose, route, time

LABS: (do not include labs already done)

Test: CT, CXR…etc (do not include labs already done)

Ancillary orders: pain management, sleeper, bowel program, PPI protection, DVT protection, PT/OT etc. 

Supportive services: There is more to being an NP than prescribing. Look at the supportive services required, PT/ OT, Dietary, REHAB, etc and make a referral. If in your opinion there is none, then state that.

Patient education: (include family if minors on disease, management and or drugs)

Follow up or disposition: Discharge planning. When coming back and why and to who?

Health maintenance and Preventive health: Age appropriate 

Reference list: Minimum 3 to support your treatment plan		

Patient Information:

Subjective:

CC (chief complaint):

HPI:

Current meds:

Allergies:

Vaccinations:

Pertinent PMHx:

Social hx:

Fam Hx:

Questions: Copy the questions you asked in ihuman here

ROS:

Physical Exam:

Test ordered and diagnostic results:

List the differential diagnosis you identified in ihuman

List your primary dx with ICD code. Briefly explain/ discuss your primary dx and the rational

List the differential Dx with ICD and a brief explanation the rational

Assessment/Plan:

Admit to: (ICU, Observation, med surge, etc)

Status: (critical ill, stable, guarded)

CODE Status:

ALLERGY:

Diet:

Activity:

Consult/ specialty services and rational:

Nursing orders: (iv, monitor, i/o etc..)

Medication/intervention: dose, route, time

LABS: (do not include labs already done)

Test: CT, CXR…etc (do not include labs already done)

Ancillary orders: pain management, sleeper, bowel program, PPI protection, DVT protection, PT/OT etc.

Supportive services: There is more to being an NP than prescribing. Look at the supportive services required, PT/ OT, Dietary, REHAB, etc and make a referral. If in your opinion there is none, then state that.

Patient education: (include family if minors on disease, management and or drugs)

Follow up or disposition: Discharge planning. When coming back and why and to who?

Health maintenance and Preventive health: Age appropriate

Reference list: Minimum 3 to support your treatment plan

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