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. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario, please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note. Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be no longer than 3-4 pages excluding the title and the references and in 12pt font.
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