Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

Research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, and Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.

Next, determine the ICD-10 classification (diagnoses). – WWW.CMS.GOV
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.