A 52-year-old male patient who is a house painter presents to the office reporting chronic fatigue and “mild” chest pain. W
A 52-year-old male patient who is a house painter presents to the office reporting chronic fatigue and “mild” chest pain. When he is painting, the chest pain is relieved after taking a break. He reports that the pain usually lasts 5 minutes or less and occasionally spreads to his left arm before subsiding. The patient was last seen 3 years ago by you, and you recommended diet changes to manage mild hyperlipidemia, but the patient has gained 30 pounds since that time. The patient’s medical history includes anxiety, vasectomy, cholecystectomy, and mild hyperlipidemia. The patient does not smoke or use other tobacco or nicotine products. The patient cares for his wife, who has multiple sclerosis and requires 24-hour care. His daughter and grandson also live with the patient. His daughter assists with the care of his wife, and his job is the major source of income for the family. The initial vital signs are: blood pressure 158/78, heart rate 87, respiratory rate 20, and body mass index 32. As part of the diagnostic work-up, an ECG, lipid levels, cardiac enzymes, and C-reactive protein (CRP) are ordered. The patient reports that he does not have time to “be sick” and says that he needs to take care of everything during this visit so he can return to work and care for his wife.
What additional information should you obtain about the pain the patient is experiencing?
What additional physical assessments need to be completed for this patient?
What differential diagnoses should be considered for the patient?
Assuming that the in office EKG did not indicate any abnormalities, how would you proceed to manage the abnormal subjective and objective findings discovered during this visit? Include specific interventions for each diagnosis in your treatment plan. Provide complete prescription details, follow up instructions, and potential referrals.
What patient teaching will be incorporated into the visit to modify the patient’s risk factors?
Include the ICD 10 codes you would choose for each problem addressed and the Evaluation and Management code expected for this visit. Keep in mind the length of time it has been since this patient has been seen in the clinic.
NU623 Adult Healthcare
Unit 2 Discussion
Arrhythmia
Scenario: A 64-year-old female patient enters the walk-in clinic reporting dizziness and fainting that has been happening off and on for the last 48 hours. The patient reports a 10-year history of hypertension, which she describes as “usually” controlled. The woman reports being recently ill with a “bad case” of influenza but otherwise well, with a history of depression controlled with antidepressant medication. The woman reports taking an ACE inhibitor daily for her hypertension and notes she has taken a dose today. Her vital signs upon arrival are: blood pressure 104/48, heart rate 180, respiratory rate 30, and temperature 99.1°F. The woman appears diaphoretic, fatigued, and weak. Physical assessment reveals an irregularly irregular heart rate, weak peripheral pulses, cool, pale skin, and decreased capillary refill. The ECG shows atrial fibrillation. The woman reveals that she is in the United States illegally and is undocumented. The patient expresses concern about her status as you prepare her for treatment.
What additional symptoms should you ask the patient if she has experienced?
Using Table 36.1, calculate the patient’s CHADS2 score and determine whether anticoagulation is recommended based on the score.
What is the significance of this condition happening off and on for the last 48 hours?
You, the nurse practitioner, decide the patient needs treatment beyond the walk-in clinic’s resources. What action do you take to ensure that the patient is treated promptly?
Because the patient is an undocumented immigrant, what considerations will be needed while care is provided?
NU623 Adult Healthcare
Unit 3 Discussion
Cough
Scenario: A 56 year-old man with a history of hypertension, diabetes, environmental allergies, and colon polyps presents to the office with a complaint of persistent dry hacking cough that does not improve with over-the-counter treatment with antitussives and allergy medications. The man reports that he has had the cough for 3 months and is tired of the coughing spells he experiences. His medical history reveals that he started taking Lisinopril 6 months before this appointment, has taken an over-the-counter allergy medication for several years, had his last colon polyps removed 6 years ago, and his blood pressure today is 145/70. Other medications include metformin XR 500 mg daily, aspirin 81 mg once daily, and loratadine 10 mg daily. The physical exam is negative for any issues other than his mild neuropathy from long-term diabetes. The cough is noted to be dry and hacking as the patient has described. The man is not in acute distress.
What questions would have been asked as part of the medical history?
What physical aspects would have been completed as part of the physical exam?
Are there any tests that should be completed before producing a diagnosis? Why or why not?
Based on the medical history and physical exam, what is the likely diagnosis? Include your differentials.
What is the treatment for this patient, including education? Any medications should include full prescribing information.
NU623 Adult Healthcare
Unit 4 Discussion
Eye Discomfort
Scenario: An 18-year-old woman is being seen in the clinic and reports that she suspects that she has contracted “pink eye” from the child she babysits. The patient denies a history of conjunctivitis. The patient has a history of environmental allergies but otherwise negative medical history. The patient normally wears contact lenses but is currently wearing glasses due to the discomfort.
What characteristics would the patient likely describe if the conjunctivitis is caused by a bacterial infection?
What objective symptoms will the patient likely exhibit?
What are the differential diagnoses for the patient?
What symptoms, if present, would indicate the need to have another professional perform a dilated pupil exam?
What treatment should be prescribed for the patient’s bacterial conjunctivitis? Include full prescribing information.
What additional patient teaching should be included?
NU623 Adult Healthcare
Unit 5 Discussion
Weight Gain and Fatigue
Scenario: A 42-year-old woman who is an established patient comes to an appointment complaining of sudden and unexpected weight gain, fatigue, and heavy menses for the past 3 months. The woman has a history of allergies, Guillain-Barré syndrome at age 18, depression, and some difficulty getting pregnant in the past. Her maternal grandmother had a history of thyroid problems, but no specific information was available.
What additional assessments should be included in the patient examination?
Explain whether this patient should have had routine screening of thyroid function.
Which testing is needed to diagnose hypothyroidism?
Why is the measurement of free T4 always preferred over the total T4?
Under what circumstances should this patient be referred to an endocrinologist for treatment?
NU623 Adult Healthcare
Unit 6 Discussion
Gout
Scenario: A 47-year-old man presents with “extreme” pain in his right large toe. The man is overweight and has consumed 12 to 16 beers daily for at least 15 years. His medical history includes hyperlipidemia and a history of gall bladder disease but is otherwise unremarkable. Today’s vital signs include blood pressure 180/96, heart rate 89, respiratory rate 24, Temperature 98.8°F, and pain reported as 8 on 1 to 10 scale. The patient has taken acetaminophen and ibuprofen for pain management with little effect. The patient says this is the first time he has experienced such pain. He has not been diagnosed with gout, arthritis, or other conditions in the past. This pain has prevented him from sleeping for 3 nights, and he appears tired. He also reports difficulty walking and completing his daily responsibilities as a farmer. The patient reports recent trauma to the toe as he dropped a heavy object on it 1 week prior; however, no obvious displacement of the joint or bruising is noted. The practitioner suspects gout is the cause of the man’s condition.
What risk factors does the man have for developing gout?
What contributing factors should be explored with the patient?
What physical assessment should be performed related to the reported pain?
What is the initial testing that should be performed after a physical assessment?
What are the differential diagnoses for this patient?
What modifications should the patient be instructed to make for treatment of the gout?
What is your initial treatment and follow up plan? Include full prescribing information.
NU623 Adult Healthcare
Unit 7 Discussion
UTI
A 28-year-old woman presents to the clinic with symptoms of a urinary tract infection (UTI) for the fourth time in 5 months. The woman describes urinary frequency and dysuria. The woman denies blood in the urine or a foul smell to the urine. A clean catch urine specimen demonstrates cloudiness, alkaline pH, increased nitrites, and leukocyte esterase. Some mucus is present, as well as bacterial overgrowth. The woman indicates that she uses proper hygiene measures by wiping from front to back, has completed the full course of antibiotics previously prescribed, wears cotton underwear, avoids tub baths, and drinks increased fluids each day to encourage voiding. Upon further discussion, the woman reveals the use of a diaphragm and spermicide for birth control. The previous urine culture from the last UTI demonstrated gram-positive cocci, which were not present in the most recent UTI culture. The woman is not currently pregnant.
What risk factor(s) for UTI does the woman demonstrate?
What are the differential diagnoses for this patient?
What additional medication management should be considered?
What patient education should be considered?
What follow-up education is important for this patient?
Would this be considered a complicated or uncomplicated UTI. What are the differences in treatment for each? How does the management change based on this knowledge?
NU623 Adult Healthcare
Unit 8 Discussion
Scrotal Pain
You are seeing a 22-year-old male patient at the college student health clinic. His chief complaint is scrotal pain and swelling. He has had some frequency of urination and purulent penile discharge, but no fever. He admits to being sexually active, with his new girlfriend of two weeks. He has tried Tylenol and ibuprofen at home and nothing helps.
As you enter the treatment room, the patient appears anxious and uncomfortable. What additional history should you obtain from the patient?
What physical examination components are indicated for this presentation?
Based on the presentation and history, you recognize the need to screen for sexually transmitted infections (STIs). What are the most common STIs for this presentation?
After your assessment, all subjective and objective findings should be considered when developing differential diagnoses for scrotal pain and swelling with accompanying urinary complaints. What may be included on a differential list?
Name your priority diagnosis and provide the treatment plan. If you elect to treat with medications, provide full prescription details and follow up plan.
As the practitioner, you are required to report certain STIs to your state health department. Provide a list of diagnoses and other required information you must report in your state.
NU623 Adult Healthcare
Unit 9 Discussion
Abdominal Pain
The nurse practitioner (NP) is working at a health clinic in a homeless shelter during the early evening. A 48-year-old African American man approaches the practitioner and asks to have his blood pressure taken, saying that he has not had it checked “in a while”. The man appears to be in some type of distress and experiencing pain. The man walks slowly, using a guarded manner, and he appears diaphoretic. His mucous membranes also appear pale. The patient’s blood pressure is 210/98. The patient reports that he has not been diagnosed with hypertension previously. The patient reveals that he has severe abdominal pain that is radiating to his back. The nurse finds a heart rate of 110, respirations 30 with shallow inspirations, and temperature 102.2°F. The patient’s skin is cool and clammy.
The patient reports a history of alcoholism, homelessness, and lack of access to health care. He says that the symptoms have been present and worsening over 3 days. The man says he thinks he might have pancreatitis again, which he had “a couple years ago”. The NP recommends that the man should be seen at a hospital for his condition, but the patient says he does not have health insurance, so he does not want to go.
The NP proceeds with a physical examination, finding severe abdominal pain in the epigastric area, yellowed sclera, no abdominal distention, and hypoactive bowel sounds. The clinic is equipped with basic materials but no means to conduct lab or radiologic testing.
Considering the patient’s homelessness and lack of insurance, what action should the practitioner take?
When the patient asks why his condition cannot be managed outside of the hospital, how should the practitioner respond?
When the patient arrives to the hospital for further diagnostic work-up, what tests will likely be performed to evaluate the patient’s condition?
What criteria is used to assess the severity of pancreatitis?
What is the treatment plan for managing this patient? If medications are to be prescribed, provide full prescription details.
What patient education should be included after the pancreatitis is resolved?
NU623 Adult Healthcare
Unit 10 Discussion
Anemia
A 65-year-old woman presents to the office with complaints of excessive fatigue and shortness of breath after activity, which is abnormal for her. The woman has a history of congestive heart failure with decreased kidney function within the last year. The woman appears unusually tired and slightly pale. Additional history and examination rules out worsening heart failure, acute illness, and worsening kidney disease. The complete blood count (CBC) results indicate that hemoglobin is 9.5 g/dL, which is a new finding, and the hematocrit is 29%. Previous hemoglobin levels have been 11 to 13g/dL. The patient’s vital signs are temperature 98.7°F, heart rate 92 bpm, respirations 28 breaths per minute, and blood pressure 138/72. The practitioner suspects the low hemoglobin level is related to the decline in kidney function and begins to address treatment related to the condition.
Case Questions
Which test(s) should be performed to determine whether the anemia is related to chronic disease or iron deficiency, and what would those results show?
Should the practitioner consider a blood transfusion for this patient? Explain your answer.
Which medication(s) should be considered for this patient? Provide exact prescription details.
What considerations should the practitioner include in the care of the patient if an erythropoietic agent is used for treatment?
What follow-up should the practitioner recommend for the patient?
Please be sure to validate your opinions and ideas with citations and references in APA format.
NU623 Adult Healthcare
Unit 11 Discussion
Spinal Disorders
A 59-year-old female presents with complaints of low back pain. She reports having difficulty standing upright and must change position frequently when sitting or lying down. She denies any specific incident that preceded the pain, stating that it just started as stiffness, but it has progressively worsened. When asked about pain radiation, the patient confirms that pain is radiating down to her mid-thighs, bilaterally. The patient reports that her activities are limited by the pain despite the use of acetaminophen, ibuprofen, and ice. A full physical exam is needed to determine the cause of pain and to identify treatment options.
The patient reports activity intolerance as a result of the low back pain. What should you include when performing your initial assessment?
What questions should you ask to appropriately gather this patient’s history?
The patient seems surprised when you begin asking questions about her psychosocial status. Why is a psychosocial evaluation important for patients with low back pain?
Concerned that “something serious” is going on, the patient insists on having an x-ray to be certain. To warrant an order for an x-ray (radiograph) for acute low back pain (ALBP), what conditions should exist?
You inform the patient that most ALBP episodes (almost 90%) resolve within 1 to 6 weeks and that pain management will focus on symptom control through pharmacological and nonpharmacological methods. What will you include in patient education and instructions?
Please be sure to validate your opinions and ideas with citations and references in APA format.
The post and responses are valued at 20 points. Please review post and response expectations. Please review the rubric to ensure that your response meets criteria.
NU623 Adult Healthcare
Unit 12 Discussion
A 35-year-old woman presents to the walk-in clinic with an erythemic rash along her left lateral rib area, somewhat under her breast, which she describes as “very painful.” You note it has a few vesicles developing. The woman has a 6-month-old infant who is breastfeeding and three other children over 3 years of age, all of whom the parents have chosen not to vaccinate against common childhood illnesses. The woman describes recent stress related to providing 24-hour care in her home to her mother, who is seriously ill. The woman is seeking treatment for the painful rash.
Which conditions should be considered as possible diagnoses?
What additional information should be gathered to make the diagnosis?
Which condition is the woman likely experiencing?
What additional information should you obtain from the patient?
What treatment plan should you prescribe for the woman?
What follow-up care should you recommend to the woman?
Based on the likely diagnosis, what are your concerns about the other members of the family?
NU623 Adult Healthcare
Unit 13 Discussion
Headache
Gina is a healthy 32-year-old lawyer who presents to the clinic with recent onset of intermittent headaches. She recently started at a new law firm and has been under a lot of stress. Her headaches can last 4 hours or more and they are a moderate to serve pulsation quality. She has had to leave work on at least 5 occasions over the last two months. During a headache, she has photophobia and nausea. Lying down in a dark room with a cold compress helps as she eventually falls asleep. Ibuprofen has been mildly effective, but she can’t tolerate it when she is nauseated. She is worried that she is missing too much work at her new job.
What should the initial history and physical examination include?
What diagnostic tests would you order and provide the rationale?
What are the differential diagnoses for this patient?
What is the most likely diagnosis for this patient? Explain your answer.
What are the first line initial treatment recommendations for management of this disorder? Provide pharmacological (with full prescription details) and nonpharmacological treatment options.
What patient education would you offer Gina?
NU623 Adult Healthcare
Unit 14 Discussion
Mood Disorders
Joe, a recently divorced, 56-year-old Caucasian man presents to you, his primary-care provider, with complaints of insomnia and fatigue. He denies any recent injury or specific pain and was last seen in your office 11 months ago. Joe has taken an antihypertensive medication to control his blood pressure for 3 years and does not report any adverse side effects. Joe has worked in law enforcement for 14 years. He recently discharged his firearm for the first time. Even though no one was injured, Joe has been attending mandated appointments with the department psychologist. Joe reports that he does not have a regular exercise regimen. To relax he typically goes fishing or has a few beers after his shift. Other than the mandated appointments with the department psychologist, Joe has not sought any mental health treatment.
What factors in the scenario demonstrate an increased risk for suicide?
What should you include in a suicide risk assessment?
During the appointment, Joe states that it’s hard for him to talk about how he is feeling and begins to cry. Taking the opportunity to ask Joe about his intentions, what specific questions could you ask?
You understand that the best predictor of suicide risk is a history of a previous suicide attempt. When asked, Joe admits to placing one of his firearms in his mouth a few times, indicating that the likelihood of Joe attempting suicide is very high. How should you proceed?
Could Joe benefit from a no-suicide contract?
NU623 Adult Healthcare
Unit 15 Discussion
Laceration Injury
The practitioner is working in the urgent care when a young woman comes in with a man who appears to be a much older boyfriend. The woman appears young but states that she is 22 years old. Despite cool weather, the woman is dressed in shorts and a t-shirt with a sweatshirt. The man stays close to her in the examination room and answers most of the questions for her. When she does respond, her answers are short and vague, with the boyfriend elaborating on her responses. There seems to be tension between the two, and the man is harsh with the woman.
The woman has a large laceration on her upper thigh, which she says she received a week ago due to falling. The wound appears red and inflamed, and has greenish yellow drainage seeping from the lower aspect. The entire anterior surface of the thigh appears swollen and red, is warm to the touch, and is painful. The wound edges are not approximated, and it appears to be a partial thickness wound about 10 cm in length. The wound appears painful, but the woman is guarded in her answers to questions about pain. The woman has a temperature of 100.5°F, heart rate of 92 bpm, respirations of 24 breaths per minute, and blood pressure 110/60. As the practitioner, you sense something is “off” between the woman and the man, who will not leave her side.
Further examination reveals bruising on both thighs and arms, all in various stages of healing. The woman has a few minor lacerations on her forearm, which are healing. While reviewing the wounds, you are reminded of a recent in-service on human trafficking. During the in-service, you reviewed the article “Red Flags: Identifying Sex Trafficking Victims in the ED” found at this website: http://epmonthly.com/article/red-flags-identifying-sex-trafficking-victims-in-the-ed (Links to an external site.)/. Participants were also directed to the National Human Trafficking Hotline found at https://humantraffickinghotline.org (Links to an external site.)/. Remembering these resources, you feel concerned for the woman’s well-being.
Case Study Questions
What additional questions should the practitioner ask about the wound?
What testing should the practitioner consider for the wound?
What treatment should be provided to the wound?
What signs suggest that this may be an abuse and human trafficking situation?
What further assessment should the practitioner perform?
Who should the practitioner involve in the care to assist in assessing for human trafficking and in providing support to the woman?
NU623 Adult Healthcare
Unit 16 Discussion
Reflection
Please respond to the following questions based upon these course objectives:
Distinguish between normal and abnormal physical and psychosocial changes associated with patients aged 18-64 years.
Identify syndromes and disease states commonly managed by advanced practice nurses in the adult population.
Critique existing protocols and best practices that address differential diagnosis, pharmacotherapeutic intervention, and resources to manage and evaluate acute and chronic illness in the adult population.
Plan and implement therapeutic interventions to return the adult patient to a stable state and/or optimize the patient’s health.
Examine state and federal resources influencing healthcare for the adult population
Effectively manage communication central to shared decision-making with other health care professionals and patients, demonstrating awareness of gender and cultural differences.
Please answer the following questions with supporting examples and full explanations.
For each of the learning objectives, provide an analysis of how the course supported each objective.
Explain how the material learned in this course, based upon the objectives, will be applicable to professional application.
NU623 Adult Healthcare
Unit 4 Assignment
Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
Medications: Names, dosages, and routes of administration.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Health Maintenance/Promotion – Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
ROS: review of systems – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when conducting your ROS to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness.]
You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/categories applicable to your patient’s chief complaint.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection] Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment. This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
Plan (P):
These are the interventions that relate to each individual, numbered diagnosis.
Document individual plans directly after each corresponding assessment (Ex. AssessmentPlan). Address the following aspects (they should be separated out as listed below):
Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.
Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. Educational: information clients need in order to address their health problems. Include followup care. Anticipatory guidance and counseling. Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. NOTE: please input N/A where appropriate for the above 4 categories, do not assume that your clinical faculty person will know it was not applicable
NU623 Adult Healthcare
Unit 5 Assignment
SOAP Note Clinical Documentation
Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, and routes of administration. Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Health Maintenance/Promotion – Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
ROS: review of systems – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when conducting your ROS to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness.] You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/categories applicable to your patient’s chief complaint.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection]
Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment. This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs. Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint. Gen: general statement of appearance, if there is any acute distress. VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis. A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up. Plan (P):
These are the interventions that relate to each individual, numbered diagnosis. Document individual plans directly after each corresponding assessment (Ex. AssessmentPlan). Address the following aspects (they should be separated out as listed below):
Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint. Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. Educational: information clients need in order to address their health problems. Include followup care. Anticipatory guidance and counseling. Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.
NOTE: please input N/A where appropriate for the above 4 categories, do not assume that your clinical faculty person will know it was not applicable
NU623 Adult Healthcare
Unit 6 Assignment
SOAP Note Clinical Documentation
Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
NU623 Adult Healthcare
Unit 7 Assignment
SOAP Note Clinical Documentation
Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
NU623 Adult Healthcare
Unit 8 Assignment
SOAP Note Clinical Documentation
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
NU623 Adult Healthcare
Unit 9 Assignment
Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
NU623 Adult Healthcare
Unit 10 Assignment
Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
NU623 Adult Healthcare
Unit 11 Assignment
SOAP Note Clinical Documentation
Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
NU623 Adult Healthcare
Unit 12 Assignment
SOAP Note Clinical Documentation
Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
NU623 Adult Healthcare
Unit 13 Assignment
SOAP Note Clinical Documentation
Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
Medications: Names, dosages, and routes of administration.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.Health Maintenance/Promotion – Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
ROS: review of systems – [Refer to your course modules and the Bickley Etext (Bates Guide) as a guide when conducting your ROS to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness.]You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.)you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list below is provided for your convenience it is not to be considered all-encompassing and you areexpected to include other systems/categories applicable to your patient’s chief complaint.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
Objective (O):
PE: physical exam – [Refer to your course modules and the Bickley Etext (Bates Guide) as aguide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection] Perform either a focused exam or comprehensive exam to ensure a comprehensive physical assessment.
This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs.
Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
While the list below is provided for your convenience it is not to be considered allencompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
Assessment (A):
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication).
Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed). Pertinent positives and negatives must be found in the write-up.
Plan (P):
These are the interventions that relate to each individual, numbered diagnosis.
Document individual plans directly after each corresponding assessment (Ex. AssessmentPlan). Address the following aspects (they should be separated out as listed below):
Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.
Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. Educational: information clients need in order to address their health problems. Include followup care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.
NOTE: please input N/A where appropriate for the above 4 categories, do not assume that your clinical faculty person will know it was not applicable
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