NRNP 6552 Week 8 Case Study Discussion: Episodic/Focused SOAP Note Template
NRNP 6552 Week 8 Case Study Discussion: Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”
ORDER A CUSTOMIZED, PLAGIARISM-FREE NRNP 6552 Week 8 Case Study Discussion: Episodic/Focused SOAP Note Template HERE
Thanks for stopping by this assessment. We can assist you in completing it and other subsequent ones. Our expert writers will comprehensively review instructions, synthesize external evidence sources, and customize an A-grade paper for YOU!!!
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A.
Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
ORDER A CUSTOMIZED, PLAGIARISM-FREE NRNP 6552 Week 8 Case Study Discussion: Episodic/Focused SOAP Note Template HERE
NRNP_6552_Week8_Case_Study_Discussion_Rubric
| Criteria | Ratings | Pts | |||
| Main Posting:
Response to the case study discussion questions includes appropriate diagnoses with explanations of appropriate diagnostic tests and treatment options as directed, is based on evidence- based research where appropriate, and is incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources. |
44 to >39.16 pts Excellent Point range: 90–100
Thoroughly responds to the discussion question(s)… Post includes appropriate diagnoses including explanations of appropriate diagnostic tests and treatment options… Incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources, with no less than 75% of post the post having exceptional depth and breadth… Supported by at least 3 current credible sources. |
39.16 to >34.76 pts Good Point range: 80–89
Responds to most of the discussion question(s).. Post includes appropriate diagnoses with explanations of appropriate diagnostic tests and treatment options… Somewhat incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources with no less than 50% of the post having exceptional depth and breadth… Supported by at least 3 credible references. |
34.76 to >30.36 pts Fair Point range: 70–79
Responds to some of the discussion question(s)… Post contains incomplete or vague diagnoses or explanations of appropriate diagnostic tests and treatment options… Is somewhat lacking in synthesis of knowledge gained from the course readings for the module and current credible sources… Post is cited with fewer than 2 credible references. |
30.36 to >0 pts Poor Point range: 0–69
Does not respond to the discussion question(s)… Post contains incomplete diagnoses or explanations of appropriate diagnostic tests and treatment options, or diagnoses and/or explanations are missing… Lacks synthesis gained from the course readings for the module and current credible sources… Contains only 1 or no credible references. |
44 pts |
| Criteria | Ratings | Pts | ||||||||
| Main Posting: Writing | 6 to >5.34 pts Excellent Point range: 90–100
Written clearly and concisely… Contains no grammatical or spelling errors… Further adheres to current APA manual writing rules and style. |
5.34 to >4.74 pts Good Point range: 80–89
Written concisely… May contain one to two grammatical or spelling errors… Adheres to current APA manual writing rules and style. |
4.74 to >4.14 pts Fair Point range: 70–79
Written somewhat concisely… May contain more than two spelling or grammatical errors… Contains some APA formatting errors. |
4.14 to >0 pts Poor Point range: 0–69
Not written clearly or concisely… Contains more than two spelling or grammatical errors… Does not adhere to current APA manual writing rules and style. |
6 pts |
|||||
| Main Posting:
Timely and full participation |
10 to >8.9 pts Excellent Point range: 90–100
Meets requirements for timely, full, and active participation… Posts main discussion by due date. |
8.9 to >7.9 pts Good Point range: 80–89
Posts main discussion by due date… Meets requirements for full participation. |
7.9 to >6.9 pts Fair Point range: 70–79
Posts main discussion by due date. |
6.9 to >0 pts Poor Point range: 0–69
Does not meet requirements for full participation… Does not post main discussion by due date. |
10 pts |
|||||
| First Response:
Post to colleague’s main post that is reflective and justified |
9 to >8.01 pts Excellent Point range: 90–100
Response exhibits critical |
8.01 to >7.11 pts Good Point range: 80–89
Response has some depth and may exhibit critical thinking |
7.11 to >6.21 pts Fair Point range: 70–79
Response is on topic, may have some depth. |
6.21 to >0 pts Poor Point range: 0–69
Response may not be on topic, lacks depth. |
9 pts | |||||
| Criteria | Ratings | Pts | ||||||
| with credible | thinking and | or application to | ||||||
| sources. | application to | practice setting. | ||||||
| practice | ||||||||
| settings… | ||||||||
| Responds to | ||||||||
| questions | ||||||||
| posed by | ||||||||
| faculty… The | ||||||||
| use of | ||||||||
| scholarly | ||||||||
| sources to | ||||||||
| support ideas | ||||||||
| demonstrates | ||||||||
| synthesis and | ||||||||
| First Response:
Writing |
6untdoe>rs5t.a3n4dpintgs
oEfxlceealrlneinntg oPbojiencttirvaensg. e: |
5.34 to >4.74 pts Good Point range: 80–89 | 4.74 to >4.14 pts Fair Point range: 70–79 | 4.14 to >0 pts Poor Point range: 0–69 | ||||
| 90–100
Communication is professional and respectful to colleagues… Response to faculty questions are fully answered, if posed… Provides clear, concise opinions and ideas that are supported by two or more credible sources… Response is effectively written in Standard, Edited English. |
Communication is mostly professional and respectful to colleagues…
Response to faculty questions are mostly answered, if posed… Provides opinions and ideas that are supported by few credible sources… Response is written in Standard, Edited English. |
Response posed in the discussion may lack effective professional communication… Response to faculty questions are somewhat answered, if posed… Few or no credible sources are cited. | Responses posted in the discussion lack effective communication… Response to faculty questions are missing… No credible sources are cited. |
6 pts |
||||
| Criteria | Ratings | Pts | ||||||
| First Response:
Timely and full participation |
5 to >4.45 pts Excellent Point range: 90–100
Meets requirements for timely, full, and active participation… Posts by due date. |
4.45 to >3.95 pts Good Point range: 80–89
Meets requirements for full participation… Posts by due date. |
3.95 to >3.45 pts Fair Point range: 70–79
Posts by due date. |
3.45 to >0 pts Poor Point range: 0–69
Does not meet requirements for full participation… Does not post by due date. |
5 pts |
|||
| Second Response:
Post to colleague’s main post that is reflective and justified with credible sources. |
9 to >8.01 pts Excellent Point range: 90–100
Response exhibits critical thinking and application to practice settings… Responds to questions posed by faculty… The use of scholarly sources to support ideas demonstrates synthesis and |
8.01 to >7.11 pts Good Point range: 80–89
Response has some depth and may exhibit critical thinking or application to practice setting. |
7.11 to >6.21 pts Fair Point range: 70–79
Response is on topic, may have some depth. |
6.21 to >0 pts Poor Point range: 0–69
Response may not be on topic, lacks depth. |
9 pts |
|||
| Second Response:
Writing |
understanding
o6ftloea>r5n.i3n4g pts oEbxjceecltliveenst. Point range: 90–100 Communication is professional and respectful to colleagues… Response to |
5.34 to >4.74 pts Good Point range: 80–89
Communication is mostly professional and respectful to colleagues… Response to |
4.74 to >4.14 pts Fair Point range: 70–79
Response posed in the discussion may lack effective professional communication… |
4.14 to >0 pts Poor Point range: 0–69
Responses posted in the discussion lack effective communication… Response to |
6 pts | |||
| Criteria | Ratings | Pts | ||||||
| faculty questions are fully answered, if posed…
Provides clear, concise opinions and ideas that are supported by two or more credible sources… Response is effectively written in Standard, Edited English. |
faculty questions are mostly answered, if posed… Provides opinions and ideas that are supported by few credible sources…
Response is written in Standard, Edited English. |
Response to faculty questions are somewhat answered, if posed… Few or no credible sources are cited. | faculty questions are missing… No credible sources are cited. | |||||
| Second Response:
Timely and full participation |
5 to >4.45 pts Excellent Point range: 90–100
Meets requirements for timely, full, and active participation… Posts by due date. |
4.45 to >3.95 pts GoodPoint range: 80–89
Meets requirements for full participation… Posts by due date. |
3.95 to >3.45 pts Fair Point range: 70–79
Posts by due date. |
3.45 to >0 pts Poor Point range: 0–69
Does not meet requirements for full participation… Does not post by due date. |
5 pts |
|||
| Total Points: 100 | ||||||||