Assignment: Diagnostic and Clinical Reasoning Paper. Use attachment A and B as your guide for paper. Using the topic of this weeks Simulation: Neurological. Select a friend or family member whom will permit you to conduct a complete history and physical exam. If there is a diagnostic test to consider to order provide the rationale WHY. Use APA format where necessary. Provide a 1-2 page document in SOAP format. Points: 75 Due Date: 4/2/17
Diagnostic and Clinical Reasoning Paper
Choose a patient from clinical which you have seen for a Health issue. Use the criteria below to formulate your diagnostic and clinical reasoning paper. You must utilize APA format for the paper.
The SOAP note (an acronym for subjective, objective, assessment, and plan), is a format of documentation employed by many health care providers to document their patient encounters. Professional documentation of patient encounters in the medical record is an integral part of practice and is also an essential component for proper billing and reimbursement. The SOAP format is one method of providing a logical analysis of data, which is consistent throughout. For example, S (subjective) and O (objective) data are all addressed and linked into the A (assessment); and all A’s (assessments) are addressed and linked into the P (Plan).
The entire SOAP is directed for some “Chief complaint” (CC), or reason you are examining the patient, such as the need to complete an assessment for the patient record. The SOAP note format can be used for all types of patient encounters including an episodic or focused health concern, chronic illness follow up, or a full history and physical examination.
When addressing a chief complaint (CC) for an episodic (focused) visit, an abbreviated exam (S and O) often is undertaken; if a more extensive data base is being collected (such as for a full history and physical), a more extensive exam may be undertaken.
This SOAP note format is reflective of a more extensive patient note than is typically completed in a clinical setting. However, this assignment/tool allows the student the opportunity to demonstrate their level of achievement of clinical and diagnostic reasoning.
The final section of your note summarizes your critical thinking and decision making skills for that particular patient encounter and is a mandatory additional requirement of this assignment. It provides the student an opportunity to demonstrate the thought process used in caring for the patient.
Components of the Diagnostic and Clinical Reasoning Paper
Title Page: (Page 1)
Include Running Head, Page numbers, Medical Diagnosis, Course title and number, Student Name, and Date submitted per APA format.
(Start of Page 2)
CC: chief complaint: What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI: history of present illness: Use the “OLDCART” which may facilitate obtaining all necessary data. 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: 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: This is 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.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
HEENT: head, eyes, ears, nose and throat
PV: peripheral vascular
PE (Physical Exam): either limited for a focused exam or more extensive for a complete history and 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. This information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
HEENT: head, eyes, ears, nose and throat
PV: peripheral vascular
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 (number each diagnosis):
Medical Diagnosis: Start with the presenting complaint diagnosis first. Number each diagnosis. A statement of current condition of all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the S and O must support this diagnosis. Pertinent positives and negatives must be found in the write-up.
Plan (number each plan specific to each diagnosis):
These are the interventions that relate to the above diagnosis and address the following aspects (they may be included in one paragraph or separated out as listed below):
Diagnostic: labs, diagnostics
Therapeutic: changes in meds, skin care, counseling
Educational: information clients need in order to address their health problems. Include follow-up 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.
Clinical Decision Making
The final section summarizes your critical thinking, decision-making and diagnostic reasoning skills and is a mandatory additional requirement of this assignment. It is a reflection of the thought process you used in caring for the patient. Follow the directions under each section and label each area as appropriate. ALL information should be in your own words. Do not cut and paste information obtained as this is considered academically dishonest.
Pathophysiology: (1 paragraph)
Include information in regards to the pathophysiology related to the main diagnosis or illness process. This will help to understand how the S and O supported this diagnosis.
Leadership / Professional Role:
Identify the specific person that drove this plan of care and developed the management, while including detail in how you advocated for the patient. Also include how you identified your advocacy for the role of the Nurse Practitioner. Include how an individualized approach was applied to this patients care.
Barriers of Care
Identify any barriers you encountered or foresee with this patients care. Demonstrate knowledge of healthcare policy and advocate for quality health care for all citizens. It is important to keep up to date with health care policy in order to provide quality patient care. This information may be obtained in journals, blogs, media, etc…
Ethical and or Cultural Concerns: Identify any ethical or cultural issues related to this patients care. Include how these concerns were addressed.
Pharmacology information (1 paragraph):
Choose one drug that was prescribed at this visit or that is taken chronically by the patient to review. Please include the name of the drug (generic and brand), class, action, excretion, side effects and interactions, why this particular drug is being prescribed for this particular patient, what is this drug intended to treat, (specifically antibiotics, what organisms are we treating?). What other drug could be chosen instead that would work? Keep in mind the cost and convenience for the patient. This should be about a paragraph in length stated in the way that you would use to educate your patient regarding the medication. It is not acceptable to copy and paste from your pharmacology resource or text. Please cite resources used.
Critical Thinking / Clinical Decision Making: (1 paragraph)
In this section, include the top 2-3 differential diagnosis. This is an area that you would want to discuss what led to the diagnosis and how you ruled out certain other differential diagnosis. You may want to include why a particular treatment was chosen, perhaps despite what the books and references say. You need to provide evidence that you are referring to your available resources and not just deferring to your preceptor. Address any personal biases related to aging, development, and independence that might interfere with delivering quality of care.
Evidence based practice (1-2 paragraphs)
Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings. The practice of Evidence-Based Practice includes five fundamental steps;
Formulating a well-built question
Identifying articles and other evidence-based resources that answer the question
Critically appraising the evidence to assess its validity
Applying the evidence
Re-evaluating the application of evidence and areas for improvement
In this section please include APA citation for all resources utilized that informed your decision making with this particular patient case. In addition, describe what clinical questions and terms used to direct your search and address how valuable the evidence you found was in understanding, and directing the care.
Critique (1 paragraph)
This is an area where you look over the data gathered and after a careful review of the available resources (i.e. text books, reference readings) will provide a reflection of what might have been added or deleted that would have made this note more conclusive or complete. This is not an area to critique the preceptor. What areas could you have changed? What areas might you have added, perhaps additional questions you should have asked in the ROS, or additional areas you may have assessed for in the PE?
APA format is required
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