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COMMON GYNECOLOGIC HEALTH CONDITIONS FOCUSED SOAP NOTE

Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses can piece together facts to construct a relevant history that can lead to assessment and treatment.

For this Focused Note Assignment, you will select a patient with common gynecologic health conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.

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

· Weston, C., Page, R., Jones-Schubart, K., & Akinlotan, M. (2018). Improving cancer screening for underserved women through an FNP student-led clinicLinks to an external site. . The Journal for Nurse Practitioners, 14(5), e101–e104. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.nurpra.2018.01.013

Practicum Resources

· Walden University Field Experience. (n.d.-a). Field experience: College of Nursing.Links to an external site.  https://academicguides.waldenu.edu/fieldexperience/son/home

· Walden University Field Experience. (n.d.-b). MSN nurse practitioner practicum manual .Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments

· Walden University Field Experience. (n.d.-c). Student practicum resources: NP student orientation .Links to an external site. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation

· HSoft Corporation. (n.d.). Meditrek Links to an external site. . https://edu.meditrek.com/Default.html Note: Use this website to log in to Meditrek to report your clinical hours and patient encounters.

· Document: Focused SOAP Note Template (Word document) Download Focused SOAP Note Template (Word document)

Clinical Guideline Resources

As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for the CDC -zika in pregnancy, etc.).

· American Cancer Society.Links to an external site. (n.d.). https://www.cancer.org/

· American College of Obstetricians and Gynecologists.Links to an external site. (n.d.). https://www.acog.org/

· Centers for Disease Control and Prevention.Links to an external site. (n.d.). https://www.cdc.gov/ Links to an external site.

· ANA Enterprise.Links to an external site. (n.d.). https://www.nursingworld.org/

· HealthyPeople 2030. (2020). Healthy People 2030 framework.Links to an external site. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/FrameworkLinks to an external site.

· The American Association of Nurse Practitioners.Links to an external site. (2020). https://www.aanp.org/

· U.S. Preventive Services Task ForceLinks to an external site. . (n.d.-a). https://www.uspreventiveservicestaskforce.org/uspstf/

Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE

· Use the Focused SOAP Note Template found in this week’s Learning Resources to complete this Assignment.

· select a patient with common gynecologic health conditions whom you examined during the last three weeks in your practicum experience. With this patient in mind, address the following in your Focused Note Template:

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 7.

BY DAY 7

Submit your 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 7.)

PRAC_6552_Week7_Assignment2_Rubric

PRAC_6552_Week7_Assignment2_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications• Allergies• Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history• Review of systems

10 to >8.0 pts

Excellent

The response throughly and accurately describes the patient's subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

8 to >7.0 pts

Good

The response accurately describes the patient's subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

7 to >6.0 pts

Fair

The response describes the patient's subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.

6 to >0 pts

Poor

The response provides an incomplete or inaccurate description of the patient's subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.

10 pts

This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

10 to >8.0 pts

Excellent

The response thoroughly and accurately documents the patient's physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

8 to >7.0 pts

Good

The response accurately documents the patient's physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

7 to >6.0 pts

Fair

Documentation of the patient's physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

6 to >0 pts

Poor

The response provides incomplete or inaccurate documentation of the patient's physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.

10 pts

This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least 3 differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

25 to >22.0 pts

Excellent

The response lists at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.

22 to >19.0 pts

Good

The response lists at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.

19 to >17.0 pts

Fair

The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

17 to >0 pts

Poor

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

25 pts

This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. 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.• Reflections on the case describing insights or lessons learned. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.

30 to >26.0 pts

Excellent

The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. A thorough and accurate disucssion of health promotion and disease prevention related to the case is provided.

26 to >23.0 pts

Good

The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate critical thinking. An accurate disucssion of health promotion and disease prevention related to the case is provided.

23 to >20.0 pts

Fair

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. Reflections on the case demonstrate adequate understanding of course topics. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies.

20 to >0 pts

Poor

The response does not address all diagnoses or is missing elements of the treatment plan. Reflections on the case are vague or missing. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing.

30 pts

This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care.

10 to >8.0 pts

Excellent

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.

8 to >7.0 pts

Good

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.

7 to >6.0 pts

Fair

Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.

6 to >0 pts

Poor

Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.

10 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting - Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused--neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 pts

Excellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.5 pts

Good

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3.5 to >3.0 pts

Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.

3 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.5 pts

Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3.5 to >3.0 pts

Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

3 to >0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting - The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 to >4.0 pts

Excellent

Uses correct APA format with no errors.

4 to >3.5 pts

Good

Contains a few (1 or 2) APA format errors.

3.5 to >3.0 pts

Fair

Contains several (3 or 4) APA format errors.

3 to >0 pts

Poor

Contains many (≥ 5) APA format errors.

5 pts

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