PRAC 6531 Week 6 Assignment: Episodic Visit Gastrointestinal Focused Note
PRAC 6531 Week 6 Assignment: Episodic Visit Gastrointestinal Focused Note
For this Assignment, you will work with a patient with a gastrointestinal condition that you examined during the last three weeks. You will complete your second Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, PMH, socioeconomic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.
ORDER A CUSTOMIZED, PLAGIARISM-FREE PRAC 6531 Week 6 Assignment: Episodic Visit Gastrointestinal Focused Note HERE
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
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
LEARNING RESOURCES
Required Readings
Fowler, G. C. (2020). Pfenninger and Fowler’s procedures for primary care (4th ed.). Elsevier.
Chapter 82, “Clinical Anorectal Anatomy and Digital Examination” (pp. 570–572)
Chapter 83. “Anoscopy” (pp. 573–576)
Chapter 87, “Office Treatment of Hemorrhoids” (pp. 596–606) specifically pp. 604 -606 external hemorrhoidal tags
Chapter 94, “Esophageal Foreign Body Removal” (pp. 676–679)
Chapter 95, “Inguinal Hernia Reduction” (pp. 680–683)
Chapter 20,: “Management of Fecal Impaction” (pp. 1382–1383)
Practicum Resources
HSoft Corporation. (2019). Meditrek: HomeLinks 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 Nursing.Links 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)Download Episodic/Focus Note Template (Word document)
To prepare:
Use the Episodic/Focused 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 based on any gastrointestinal conditions. 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 6.
BY DAY 7
Submit your Episodic/Focused Note Assignment. (Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6.)
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
To submit your completed assignment, save your Assignment as WK6Assgn2_LastName_Firstinitial
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select Submit Assignment for review.
Rubric
PRAC_6531_Week6_Assignment2_Rubric
PRAC_6531_Week6_Assignment2_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning Outcome Organization of Write-up
30 to >26.0 pts
Excellent
All information organized in logical sequence; follows acceptable format
26 to >23.0 pts
Good
Information generally organized in logical sequence; follows acceptable format
23 to >20.0 pts
Fair
Errors in format; information intermittently organized
20 to >0 pts
Poor
Errors in format; information disorganized
30 pts
This criterion is linked to a Learning OutcomeThoroughness of History
20 to >17.0 pts
Excellent
Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information
17 to >15.0 pts
Good
Documents most pertinent history components; includes critical information
15 to >13.0 pts
Fair
Fails to document most pertinent history components; Lacks some critical information or rambling in history
13 to >0 pts
Poor
Minimal history; critical information missing
20 pts
This criterion is linked to a Learning OutcomeThoroughness of Physical Exam
10 to >8.0 pts
Excellent
Thoroughly documents all pertinent examination components for type of note
8 to >7.0 pts
Good
Documents most pertinent examination components
7 to >6.0 pts
Fair
Documents some pertinent examination components
6 to >0 pts
Poor
Physical examination cursory; misses several pertinent components
10 pts
This criterion is linked to a Learning OutcomeDiagnostic Reasoning
10 to >8.0 pts
Excellent
Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests
8 to >7.0 pts
Good
Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.
7 to >6.0 pts
Fair
Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests
6 to >0 pts
Poor
Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests
10 pts
This criterion is linked to a Learning OutcomeTreatment Plan/Patient Education
10 to >8.0 pts
Excellent
Treatment plan and patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Evidence based decisions. Cost effective treatment. Reflection is thoughtful and in depth.
8 to >7.0 pts
Good
Treatment plan and patient education addresses most issues raised by diagnoses. Reflection is thoughtful and in depth.
7 to >6.0 pts
Fair
Treatment plan and patient education fail to address most issues raised by diagnoses. … Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.
6 to >0 pts
Poor
Minimal treatment plan and/or patient education addressed … Reflection is absent.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.
10 to >8.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
8 to >7.0 pts
Good
Contains a few (1-2) grammar, spelling, and punctuation errors.
7 to >6.0 pts
Fair
Contains several (3-4) grammar, spelling, and punctuation errors.
6 to >0 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.
10 to >8.0 pts
Excellent
Contains parenthetical/in-text citations and at least 3 evidenced based references are listed.
8 to >7.0 pts
Good
Contains parenthetical/in-text citations and at least 2 evidenced based references are listed
7 to >6.0 pts
Fair
Contains parenthetical/in-text citations and at least 1 evidenced based reference is listed
6 to >0 pts
Poor
Contains no parenthetical/in-text citations and 0 evidenced based references listed.
10 pts
Total Points: 100