Advanced health assessment and diagnostic reasoning
In this journal activity you will submit a Kaltura video and subjective note, demonstrating your skill in completing a subjective patient interview. Use the Unit 2 Journal Template.
You will use a live person volunteer, not a patient, and conduct the interview as a professional medical provider. Prepare in advance with your questions and knowledge of the components. Be sure to read the required readings and watch the videos assigned in the readings. Your final production video will be about 5 minutes, and should not exceed 6 minutes; so your preparation and succinctness in the process and moving the patient through the interview is important. Your communication should be clear and concise; smoothly transitioning.
This is an existing patient and much of the health history can be reviewed rather than initially collected. The patient’s family history and medical history would have been assessed on prior visits. You should briefly confirm the record and include it in the documentation. Have your questions ready as you conduct the interview.
Health preventive screenings should be addressed on a well-visit. All components of the subjective interview should be included in the documentation. The review of systems, ROS, interview process and topic names can be somewhat different based on EMR. It is important to be adaptable to minor changes in EMRs, templates and format based on medical facility use and preference.
Finally as a part of this assignment include how the nurse practitioner considers gender, culture, ethnicity and ethical decision making during the patient interview process for this case and in general. Include 2-3 evidence-based resources. Be sure to include OLDCARTS in the HPI.
See the Journal Template for Unit 2.
This assignment is the subjective part of the medical visit. You are not touching the patient.
Journal Requirements:
Before finalizing your work, you should:
be sure to read the journal description carefully;
consult the grading rubric (located in Course Resources, Grading Rubrics submodule) to make sure you have included everything necessary; and
utilize spelling and grammar checks to minimize errors.
Your writing assignment should:
follow the conventions of Standard English (correct grammar, punctuation, etc.);
be well ordered, logical, and unified, as well as original and insightful;
display superior content, organization, style, and mechanics; and
use the template provided
use APA 7th edition format.
See attached template
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