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Revision, Clinical Modification

Create a SOAP note using the attached case study and SOAP template 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.
Visit the online library and 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, Healthy People
2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). 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.