Consider interactions you have had with a primary care health care providers in recent years.
Primary Health Providers
Consider interactions you have had with a primary care health care providers in recent years.
Now that you have reviewed models for clinical decision-making construct a discussion that reflects on an encounter you have had with a primary care provider.
Utilize one of the models presented in your lecture materials, or any other model that you may like, to frame your discussion of the experience with the primary care provider that you are reflecting on.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
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.
NU611 Clinical Decision Making
Unit 2 Discussion
New Patient Encounter
Instructions:
Review the SOAP note accessed through the link below. For purposes of the assignment the patient is an ‘new patient’ in the practice.
New Patient SOAP NotePreview the document
Initial Post
Use your lecture materials to determine what CPT E&M Code to utilize for this ‘new patient’ encounter.
Provide justification for the code you assigned by including the following information in your discussion:
the level of history taking achieved – identify the history elements present
the type of exam performed – identify the number of systems and bulleted points in the note
the level of medical complexity encompassed – include # of points for a) diagnoses/management options, b) amount/complexity of data reviewed and c) level of risk for complications, morbidity, mortality
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
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.
NU611 Clinical Decision Making
Unit 3 Discussion
ICD-10 Codes
Instructions:
Review the SOAP note accessed through the link below.
ICD-10 SOAP NotePreview the document
Initial Post
Use your lecture materials to determine what ICD-10 Codes to assign for this patient encounter.
In paragraph form construct a discussion that supports the Codes you identified.
In the discussion explore how the ICD-10 Codes that you assigned impact third party payor reimbursement for this visit.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
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.
NU611 Clinical Decision Making
Unit 4 Discussion
Social Determinants of Health
Instructions:
Review the SOAP note accessed through the link below.
Social Determinants SOAP NotePreview the document
Initial Post
Consider the knowledge you have gained from this week’s lecture.
Use your lecture materials to determine three priority Social Determinants of Health (SDH) to assess for in the patient represented in the SOAP note. NOTE: Priority may refer to a strength in a SDH category necessary for the individual to attain/maintain health OR the priority may be a challenge in a SDH category identified as needing support or intervention for the individual to attain/maintain health.
In paragraph form construct a discussion that identifies those priority SDHs using data from the objective and subjective data sets where appropriate to support your discussion.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
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.
NU611 Clinical Decision Making
Unit 5 Discussion
Cultural and Spiritual Assessment
Instructions:
Conduct a comprehensive cultural and spiritual assessment on a patient that you see in your clinical experience in NU 610 this week. If you were are not in clinical this week conduct this assessment on a professional colleague, friend or family member.
Document the assessment in the context of a subjective data set that you will use as your discussion post. Use one of mnemonics presented in this week’s lecture materials to guide your spiritual assessment.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
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.
Estimated time to complete: 2 hours
Peer Response: Unit 5, Due Sunday by 11:59 pm CT
Cultural and Spiritual Assessment
Instructions:
Construct a response to at least 2 of your peers commenting – ideally one who utilized the same mnemonic that you did and one who did not
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
NU611 Clinical Decision Making
Unit 6 Discussion
Health Promotion
Instructions:
Initial Post
Review the health maintenance guidelines presented in this week’s lecture material.
Post a discussion on your observations about review of these guidelines with a patient that you and your preceptor have seen in clinic.
Include in the discussion:
The patient’s age, gender and applicable health maintenance guideline
The preceptor’s approach to the topic of the health maintenance guidelines
The patient’s response to or questions about health maintenance guidelines
An overview of the health promotion model, or change model, that you would utilize to frame your discussion with a patient about health maintenance guidelines applicable for their age, gender, and health status
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
NU611 Clinical Decision Making
Unit 7 Discussion
Evidence-Based Practice
Instructions:
Review the partial SOAP note accessed through this link.
EBP SOAP NotePreview the document
Initial Post
Post a discussion constructed as the ‘P’ (treatment plan) that completes the partial SOAP note accessed through the link above.
Include in the discussion:
Your treatment plan for the first two diagnoses – structure your Plan using the format outlined in your Typhon documentation policy (e.g. diagnostics, therapeutics, educational, consultation/collaboration) Citations for each of the evidence-based practice (EBP) interventions included in your Plan For each article you cited in support of an element of the Plan provide your thoughts about the strength of the evidence presented in the article(s) Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
NU611 Clinical Decision Making
Unit 8 Discussion
Clinical Practice
Post a discussion constructed as the ‘P’ (treatment plan) that completes the partial SOAP note accessed through the link below.
Include in the discussion:
Your treatment plan for the diagnosis that relates to the “chief complaint” – structure your Plan using the format outlined in your Typhon documentation policy (e.g. diagnostics, therapeutics, educational, consultation/collaboration)
Citations for each of the guidelines/evidence used to support the elements of your Plan
Construct a narrative discussion that identifies how your Plan either aligns with or does not align with the diabetes management regimen that is documented in the subjective data set (the ‘S’)
NU611 Clinical Decision Making
Unit 9 Discussion
Clinical Experience
You have been reviewing SOAP or partial SOAP notes in prior units.
For the patient encounter from your last week clinical experience construct a SOAP note.
Use your ‘model’ thinking as you construct each element of the SOAP note to ensure that each element of the note is consistent/congruent with the other sections and that you have adequate subjective and objective data that support your ‘assessment’.
Elements of the ‘plan’ need to reflect current EBP and CPGs. Be sure to include appropriately constructed in-text citations. Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate. 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.
NU611 Clinical Decision Making
Unit 10 Discussion
Social Determinants of Health
Reflect on a patient that you assessed during your clinical experience this week or last week.
Instructions:
Select one of the tools/instruments presented in Unit 4, or one you locate on your own, and construct a discussion that encompasses your assessment findings relative to your patient’s social determinants of health.
Reconstruct the elements of your patient’s ‘Plan’ that encompasses interventions aimed at challenges/issues identified for one of your patient’s social determinants of health categories.
Include citations for each of the resources you used to support the elements of your Plan.
NU611 Clinical Decision Making
Unit 11 Discussion
Spiritual Assessment
Instructions:
Select one of the mnemonics presented in the Unit 5 articles, or one you locate on your own, and construct a spiritual assessment on one of the patients that you encountered last week and create a ‘Subjective’ data set for the patient.
Construct a discussion of your spiritual assessment findings and how you or the patient perceive they may impact the patient’s health care choices.
Outline a ‘Plan’ with interventions you would implement to support identified spiritual strengths or address/support spiritual challenges for your patient.
Include citations for each of the resources that you used to support those elements of your Plan.
NU611 Clinical Decision Making
Unit 12 Discussion
Ethnicity and Culture
Instructions:
Review these videos:
Select one of the video scenarios for the purpose of constructing your discussion thread assignment.
Include in your discussion the following:
Your personal thoughts or experiences with patients of the same ethnic background as the patient in one of the videos.Best practice strategies from the literature for the development of health care approaches for patients from the culture of the patient in the video you have expressed your personal thoughts and experiences with.
Support the discussion of best practice strategies with professional literature and be sure to include appropriate in-text citations.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
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.
NU611 Clinical Decision Making
Unit 13 Discussion
Data Set Analysis
Instructions:
Review the ‘S’ and ‘O’ data sets accessed through this link.
Data Set SOAP NotePreview the document
Construct a discussion that includes the following:
An ‘Assessment’ (‘A’ of a SOAP note) section that is supported by the data sets reviewed.
Assignment of an ICD-10 Code for each diagnosis you included in your ‘A’
Identification of the subjective and objective data for each of the ‘Assessments’ (diagnoses) you included in the ‘A’.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
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.
NU611 Clinical Decision Making
Unit 14 Discussion
Current Procedural Terminology
Instructions:
Review the SOAP notes accessed through this link.
(Links to an external site.)Current Procedures SOAP NotePreview the document
Construct a discussion that includes the following:
Identification of the procedures performed in each patient encounter
Assignment of CPT code for each procedure identified
Resources utilized for locating assigned CPT codes; if an online resource include the link to the site or page.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
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.
NU611 Clinical Decision Making
Unit 15 Discussion
Evaluation and Management
Instructions:
Review this resource:
Evaluation and ManagementPreview the document
Construct a discussion that includes the following:
Assignment of the Evaluation and Management (E&M) CPT Code for each of the patient encounters
Justification of the CPT Code you assigned for each patient encounter
Resources utilized for determining the E&M CPT codes; if an online resource include the link to the site.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
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.
NU611 Clinical Decision Making
Unit 16 Discussion
Reflection
Here are the course learning objectives for your review:
Examine clinical decision-making models
Investigate healthcare coding systems
Identify key assessments that have the potential to impact the patient decision-making
Explore scholarly literature relative to patient care decision-making requirements
Integrate key concepts from clinical decision-making models to develop a personal approach to clinical decision-making
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