Please be as detailed as possible.The patient information is attached as well as the template that must be used. Follow the rubric
Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses can piece together facts to construct a relevant history that can lead to assessment and treatment.
For this Focused Note Assignment, you will select a patient with common gynecologic health conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
RESOURCES
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
- Use the Focused SOAP Note Template found in this week’s Learning Resources to complete this Assignment.
- select a patient with common gynecologic health conditions whom you examined during the last three weeks in your practicum experience. With this patient in mind, address the following in your Focused Note Template:
Assignment:
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently in a similar patient evaluation?
Note: Your Focused Note Assignment must be signed by Day 7 of Week 7.
PRAC_6552_Week7_Assignment2_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications• Allergies• Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history• Review of systems |
| 10pts | ||||
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses |
| 10pts | ||||
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least 3 differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. |
| 25pts | ||||
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.• Reflections on the case describing insights or lessons learned. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. |
| 30pts | ||||
This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care. |
| 10pts | ||||
This criterion is linked to a Learning OutcomeWritten Expression and Formatting - Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused--neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
| 5pts | ||||
This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation |
| 5pts | ||||
This criterion is linked to a Learning OutcomeWritten Expression and Formatting - The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. |
| 5pts | ||||
Total Points: 100 |