Diagnosis Cerebral Infarction of the patient who leaves in a skilled nursing facility.
August 25, 2024August 25, 2024
Discipline: Nursing
Diagnosis is Cerebral Infarction. My professor did not approve because of the following needs to be fix; COMMENTS: 1. You are missing a lot of your neurological assessment. 2. Do not document things that are impossible for you to have assessed: Ears: good cone of light, pearly gray, tympanic membranes intact bilaterally. There is no way for you to have seen this as you do not have an otoscope. 3. Where is the subjective data that belongs in each body system of your physical assessment?
The SOAP note needs to be change due to the subjective data needs to belong in each body system of the physical assessment. The patient is in the skilled nursing facility which is no equipment to do head to toe assessment. Please help.
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