Hi! please complete the following assignment ASAP. Make sure to use the gathered information to complete a SOAP note (Subjective, Objective, Assessment and Plan) and SBAR . REMEMBER THAT YOU ARE ONLY PUTTING SUBJECTIVE DATA NOT OBJECTIVE (THERE IS NONE IN THIS CASE). SUBJECTIVE DATA IS ONLY OF WHAT THE PATIENT STATED. DO NOT MAKE THINGS UP OR COPY FROM THE EXAMPLE I PUT. MUST BE THE INFORMATION I PUT. Example is attached. This must be detailed and accurate to the information i LISTED. NO GRAMMAR ERRORS.
-You must begin with stating the situation like” patient is a 37 year old man…”
Here is the information you will be using:
-Pt denies smoking.Has 1 drink a week of alcohol socially when with family.Drinks coffee.Pt explained how he is from Cuba, but lived in Mexico.Pt stated he arrived to the USA in Feb 2022. Pt explained since he entered the USA,he has gained 20 lbs.Pt had no history of surgeries, no medications, and no usage of supplements.Family history: Grandpa was diagnosed with prostate cancer in 2017. His mom had obesity and was diagnosed with hypothroidism.Social History: Pt is a clinical researcher, lives with wide, child, and other family members. Pt stated how 2 days ago,he now has insurnace under “Oscar Insurance”.
– Excercise and Regime: pt explains how he excerices 5x a week now, but when he use to work a lot, he wasnt able to as much.Pt explains that he tries to eat well. Says before, he lived a sedentary lifestyle.Pt explained how he developed obesity due to stress factors such as his job.
-Mental health Assessment was conducted: pt explains how safe he feels in his home .Patient expaline sthat he does the following to destress:swimming, reads books, and goes to thebeach. Pt explains how his wife was diagnosed with depression.Pt expresses goals such as losing weight step by step.Pt says he weighs 207 ls and wants tobe at 180 lbs.
– Pt currently does not have a provider due to new insurance rolling in.
WHEN WRITING THE PLANNING:
– include that the patient will be provided supportwith his insurance to findlocal providers.
-include encouraging lifestyle choices and techniques for reduction in stress
-inlcude other RECOMMENDATIONS that are pertinent to this case.
