Soap note nursing assignment

Announcement – Week 3

hope you all had a good weekend !

This week you have your first soap note due. It should be on the HEENT system.

Make sure your Cheif complaint is in line with your HPI, physical exam, DD, treatment and plan.

It is like telling a story.

If you have any question please reach out. Please make sure it is on this weeks reading. All pages must be signed by the preceptor.

Episodic Visit: HEENT Focused Note

Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly learning resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will work with a patient with a HEENT condition that you examined during the last three weeks, and complete an Episodic/Focus Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. In this week’s Learning Resources, please refer to the Focused SOAP Note resources for guidance on writing Focused Notes.

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

· Fowler, G. C. (2020). Pfenninger and Fowler’s procedures for primary care (4th ed.). Elsevier.

· Section 4: Eyes, Ears, Nose, and Throat

· Chapter 62, “Cerumen Impaction Removal” (pp. 388–392)

· Section 13: Urgent Care

· Chapter 200, “Corneal Abrasions and Removal of Corneal or Conjunctival Foreign Bodies” (pp. 1338–1344)

· Chapter 201, “Slit-Lamp Examination” (pp. 1345–1349)

· Chapter 202, “Auricular Hematoma Evacuation” (pp. 1350–1354)

· Chapter 204, “Removal of Foreign Bodies from the Ear and Nose” (pp. 1359–1364)

· Chapter 205, “Management of Epistaxis (pp. 1365–1371)

Practicum Resources

· HSoft Corporation. (2019). Meditrek: Home .Links to an external site. https://edu.meditrek.com/Default.html Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.

· Walden University Field Experience. (2019a). Field experience: College of NursingLinks to an external site. . https://academicguides.waldenu.edu/fieldexperience/son/home

· Walden University Field Experience. (2019b). Student practicum resources: NP student orientation. Links to an external site. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation

· Walden University. (2019). MSN nurse practitioner practicum manual .Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments

· Document: Episodic/Focus Note Template (Word document)

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 Episodic/Focus Note Template found in the Learning Resources for this week to complete this assignment.

· Select a patient that you examined during the last three weeks that suffered from any HEENT condition. With this patient in mind, address the following in a Focused Note:

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 3.

By Day 7

Submit your Episodic/Focused Note Assignment.

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