Please make a SOAP Note: Person with

Please make a SOAP Note: Person with Stroke Please see below example: SOAP Note: Person with Cataracts SUBJECTIVE: Chief concern/complaint: Mrs. L, 78 years old, is lately experiencing blurring of her vision. She also complains of experiencing glares and halos whenever she looks at bright lights even for a split second. History of illness: She ignored all of the symptoms, attributing them to tiredness. After a month, she consulted a physician because the lens of her eye now has a milky center. She is scheduled for a surgical procedure—intraocular lens implant. She has been diagnosed with Type 1 diabetes and hypertension. Social history: Mrs. L. completed a 10th grade level of education, has a low income status, and smoked for over 35 pack-years. Family history: Mother: Deceased at age 70 yo. Diabetic. Bilateral Cataracts. Father: Deceased at age 79 yo. Physical Review of Body Systems: Head- No headaches or dizziness. Eyes- Blurred vision. Positive for double vision, glaring and halos. Ears- No ringing in ears (tinnitus) Cardiovascular- No palpitations or chest pain. Mild edema of lower extremities. Endocrine- Diabetes diagnosed at 65 years old. OBJECTIVE: Physical exam- Vitals: T-98.6oF, P-86, R-20, BP-142/90, Ht- 5’5″ Wt- 195lbs Eyes: Bilateral centralized opacities. Visual acuity Left eye 20/60; Right eye 20/40 ASSESSMENT: Bilateral nuclear cataracts. Type 1 diabetes. Hypertension. Disturbed visual sensory perception related to altered sensory reception or status pf sense organs. Risk for trauma related to poor vision and reduces hand-eye coordination. PLAN: Pre-operative care- Use of anticoagulants is withheld to reduce the risk of eye hemorrhage. Eye drops as ordered. Post-operative care- Eye drops as ordered. Activities: No coughing, sneezing, bending over. Protective eye patch: To prevent accidental rubbing or poking of the eye, the patient wears a protective eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks. Expected side effects. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days, and a clean, damp washcloth may be used to remove slight morning eye discharge. Notify the physician. Because cataract surgery increases the risk of retinal detachment, the patient must know to notify the surgeon if new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness occurs. Quit smoking. The patient should avoid smoking because it is one of the greatest contributing factors to cataract. Wear sunglasses. Wearing of sunglasses shields the eye from too much exposure to UV rays that predisposes to cataract. S.O.A.P. NOTE DOCUMENTATION TEMPLATE STROKE SUBJECTIVE DATA (Statement of patient): Chief Concern/Complaint—History of illness—Social history—Family history—Physical review of body systems— OBJECTIVE DATA (Observations): Physical exam— ASSESSMENT (Medical illness diagnosis; nursing diagnosis, etc.): PLAN (Based on S.O.A. data what interventions will be ordered for the person?): First think about the IDPH CNA Skills (e.g. vital signs, mobility orders, etc)You may include treatment plans

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