Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.

Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.

Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.

Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.

SOAP NOTE TEMPLATE

**Please delete the instructions in each section prior to submitting the assignment

Student Name: Date: Course:

Subjective:

Patient Demographics: (age, gender, gender identity, ethnicity, etc.)

Chief Complaint: “quote patient”

History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)

PMH: dates in reverse chronological order.

PSH: surgery dates in reverse chronological order.

Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies

Untoward Medication Reactions: include type of reaction/severity/date

Immunization Status: e.g. Flu, COVID, TdaP, etc.

Screenings: In this section you will document any age-appropriate screenings the patient had prior to the visit today. For example, dental visits, PAP, colorectal screening, microfilament, etc… (Indicate if results were normal or abnormal)

FMH: document genetically relevant conditions of immediate family members (parents, children, siblings, and grandparents). If history is unknown then document “history unknown” for the family member you inquired about.

Personal History/Social History: Occupation, home environment, relationship status, nutrition, exercise, and substance use (smoking, alcohol, illicit drug use)

Females: LMP and relevant OB/GYN history Gravida, Para, Abortions, Living (G__P__A__L__)

If prior pregnancies document any pregnancy or postpartum complications.

Sexual History: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception

Current Medications/OTCs/Supplements: indicate Dose, Route, Frequency (write either class of medication or indications for use in parentheses)

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI. Complete a full ROS for a comprehensive/well exam visit.

Review of Systems:

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Breasts:

Respiratory:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Peripheral Vascular:

Musculoskeletal:

Neurologic:

Hematologic:

Lymphatic:

Endocrine:

Psychiatric:

Objective:

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI. Complete a full PE for a comprehensive/well exam visit.

Physical Exam:

Vital Signs: Blood Pressure- P- RR- T- Height- Weight- BMI-

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Neck:

Breasts:

Lungs:

Heart:

Abdomen:

Genitourinary:

Rectal:

Peripheral Vascular:

Lymphatic:

Extremities: Musculoskeletal:

Neurological:

Assessment:

Differential Diagnosis Diagnostic Reasoning Exercise: Minimum of 3 differential diagnoses/maximum of 5 differentials—the table will help with the narrative write-up required below the table.

In a narrative format explain how you arrived at your final diagnosis or working diagnoses based on the CC/HPI, PMH, PSH, ROS, & Physical Exam (pertinent +/– will guide this process). This should be written using examples of how the history/clinical presentation led to the final diagnosis or working diagnosis (APA citations to your references must be included – use resources with Evidence Based Guidelines)

Plan:

Include a brief summary of the visit here

(APA citations required in your plan)

In this section, you would list the diagnosis that you assessed for your patient. The Diagnosis is your primary/working diagnosis made at the time of the visit. If you have not made a diagnosis, then you would use the ICD-10 code for the symptomatology since r/o diagnoses are not billable. This should be followed by a plan of care that is evidenced based.

Diagnosis ICD-10 (must be related to CC/HPI)

· Treatment

· Lab/test

· Referral

· Education

· Follow up

Health Maintenance: Required App for USPSTF screening guidelines https://epss.ahrq.gov/PDA/index.jsp

Must list all screenings/lifestyle recommendations that are age appropriate (e.g. seasonal flu vaccine, HIV screening; STI screenings, obesity—nutritional/exercise counseling; smoker—tobacco cessation program, etc. even though you may not address in an episodic visit)

RTC: (Document disposition)

References (APA Format)

How personal & ethical values(equality, valuing other, fairness ) can be applied in the context of people practice ?

1- explain what is meant by ethical values + academic insight

2- explain all 4 example of personal values (quality, valuing other, fairness, responsibility ) how do these affect your work and working relationship? how aligned are your personal values to organization values, what can you do if they are different ? ( use made up orginazaion wit different results aligned and not aligned)

+use cipd refrences fact sheets about ethical practice +

You are opening a chain of bakeries in several cities within Ontario, Canada, with the intention of selling fresh baked bread and other baked products. You will also be serving simple, fast and fresh dishes such as sandwiches and soups. Your organization is planning to use only the freshest ingredients. Your chain of bakeries will only use locally sourced ingredients, and support the farmers of Ontario, resulting in a mutually beneficial relationship. You will offer customers all the baked goods and easily accessible menu items that are available to them in leading and contemporary bakeries and coffee shops etc. within Ontario. In addition, you intend to sell some creative items to set your business apart from the competition (for e.g. soups with interesting flavours and sandwiches designed creatively, with unique names). You will be opening 6 bakery locations at present, with a staff of 10 in each location. Thus, your total staff throughout Ontario at present will be 60 people altogether. Through voluntary self-disclosure, employees have shared that more than 50% of them have young children. About 30% are looking after their elderly parents. You are also aware that 70% of the staff will be commuting to work through driving their own automobiles, and you have become aware that some of them are worried about continuously rising parking costs and fuel costs.

To do for your video presentation:

• Come up with a creative and interesting name for the bakery/business
• Devise a mission statement for the business (keep in mind the 10 questions and evaluation criteria mentioned in the text, which help organizations rate their mission statements, and which also help them ascertain how effective their mission statement is.
• You want to provide training to the wait staff  (especially waiters) to help set them apart, and help ensure that customers have a unique and great experience. Describe 3 ways in which your bakery’s wait staff would be different, in terms of their training, skills and approach towards the customers, from the staff of an average, non-specialized bakery. (For example, you can think about the differences in staff training when it comes to Tim Horton’s vs. Starbucks.) Another way to look at it: Think about what traits you would like to see in the wait staff at a bakery such as this.

• As a savvy business owner, you are aware of the issues and concerns employees in Canada have regarding Work-Life Family Balance. You know some important facts such as:
• Canadian workers are feeling more stress, caused by an insufficient salary, work overload, and a negative work environment.
• About half of Canadian workers spend 22 hours a week on childcare, and about 25 percent spend 9 hours a week on elder care.
• Work-life conflict negatively impacts performance, causing employees to be absent from work, reduce productivity, and increase use of benefits.

Using your analytical skills and the information shared earlier about your workforce/employees, list 5 ways in which the employer/business can help employees achieve Work-Family Balance, and address some of the challenges employees face in this regard.