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SOAP NOTE Summary: 19y/o Female, African American Fainted 4days ago with the loss of consciousness. C/O blurred vision, palpitation, and SOB, with loss of consciousness. Denies loss of bowel or bladder control, shaking, rapid eye blinking, or body stiffness. Denies ilicict drugs or alcohol use. When the level of consciousness returned, the patient was confused. This situation has never happened before.
Physical Assessment: unremarkable (everything WNL)
Diagnosis: Syncope and Collapse unknown etiology
Plan of Care: Drink plenty of fluids. Cardiology referral for further workup.
ASSIGNMENT:
Submit SOAP notes with attached evidence-based article summary (The attached article needs to be summarized).
The article should be assessed for evidence and quality level with the Johns Hopkins Nursing Evidence-Based Practice checklist (the check list needs to be completed)
The important information should be synthesized and the student should explain how this either reinforces what they did in clinical or how it might change the care or plan of care that was provided. (the article should be compare to the John Hopkins check list and the plan of care in the SOAP note)
Use the checklist to assess the quality of the evidence presented in the article.
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