Research for current scholarly evidence (NOT OLDER THAN 5YEARS PLS) to support your nursing actions. USE government sites such as the CDC, WHO, AHRQ, and 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.
|The submission included the patient’s interpretation of current medical problem, chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.|
|Objective DataThe submission included measurements and observations obtained by the nurse practitioner. It included head to toe physical examination as well as laboratory and diagnostic testing results and interpretation (especially those that pertain to the diagnosis).|
|AssessmentThe submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.|
|Plan of CarePlan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.|
|APAUsed APA standards consistently and accurately when citing in the SOAP note and reference page. Utilized proper format with coversheet and header.|