In this course we covered the assess-diagnose-treat model that you will be using as an APRN.

INSTRUCTIONS:

For this assignment you will be providing a patient report. You are all familiar with RN shift change reporting. We are now moving this onto the provider level. As an APRN student you will be seeing patients in clinicals and “presenting” them to your preceptor and/or attendings. You will do this regularly throughout your rotations. In this course we covered the assess-diagnose-treat model that you will be using as an APRN. Here is your first chance to apply that. You will be recording via Kaltura, a full patient presentation to be graded. You will choose a chief concern from the list below. You can make up the rest. Make sure to clearly plan an outline for this and cover all the required points. You must research the diagnosis you are giving your patient and ensure your workup and plan of care are correct and evidence based. 

You must review the rubric below to ensure you do not miss any points. Remember this is advanced pharmacology. Every patient will require a medication that must be included in your presentation and must be the correct choice. This assignment will be a great set up for what you will be doing in your clinical courses. This is likely your first time presenting a patient in this format. The expectation is not perfection, but rather to begin to develop a foundation for this crucial aspect of APRN practice. You may use notes during the video or any other written resource. The rubric is below. Be sure to review your video against the rubric prior to submission. 

Remember to verbally cite your evidence-based source. (i.e. “This treatment plan is per UpToDate on the management of asthma”.) 

Chief concerns to use (pick one): 

• 21 year old male with fever and respiratory distress 

 RUBRIC

Category Description Points

Patient demographics Student includes patient’s age and gender      3

Chief concern Student includes what the patient presented for today      5

HPI Student includes a detailed HPI. This must include many of the relevant points relating to the CC. This also must include some pertinent negatives relating to the CC.      20

Physical exam Student should detail the physical exam performed that relates to the CC.      12

Workup Student will detail appropriate orders for diagnostic work up. This includes labs, imaging, ECG, diagnostic procedures (LP), etc. Points will be deducted for overordering completely unnecessary exams.      22

Differential diagnosis Student will list no fewer than four likely diagnosis. These must be relatively related to the CC and a way to confirm or rule out each of these must be included in the workup above.      14

Diagnosis and treatment Student will include their suspected diagnosis and offer a treatment plan. This will include the following as needed: Admission decision, medications, consideration for social/economic/ religious/cultural/ethical or other such factors, procedures, rehab, etc. Must be evidence based and you should verbally cite your sources (i.e. Clinical Practice Guideline, uptodate, AHA, etc)       24

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