A) Please fallow instruction. I need you to make up a soap note for a female patient with diagnoses of Chlamydia. Please fill out the template. I include the soap note template you must plug the information, the rubric to follow in separate attachments. I need you to provide the following: APA format with references at least no older than 5 years.
- 1)The Diagnosis ICD 10 code
- 2) 3 differential diagnoses with ICD 10 code.
- 3)Vital sign, BMI
- 4)Complete Chief patient compliant
- 5)Subjective Information
- 6)PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.
- 7)Complete Objective Information
- 8)Lab Tests
- 10)Complete physical exam with critical elements related to subjective data.
- 11)Perform Assessment
- 12)Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
- 13)Create a Plan
- 14)Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.
- 15)Self-Assessment & Clinical Guidelines
- 16)Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.
B) Discuss of Chlamydia