Focused note

Week9_Assignment2FocusedNote.pdf

For this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks. You will complete your third Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, previous medical history (PMH), socio-economic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.

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.

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 musculoskeletal 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?

EPISODIC VISIT: MUSCULOSKELETAL FOCUSED NOTE

RESOURCES

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

WEEKLY RESOURCES

9/23/24, 12:55 PM Week 9: Assignment 2

https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 1/5

https://waldenu.instructure.com/courses/131456/files/9870301/download

https://waldenu.instructure.com/courses/131456/modules/items/4993252

PRAC_6531_Week9_Assignment2_Rubric

Note: Your Focused Note Assignment must be signed by Day 7 of Week 9.

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 9.)

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.

1. To submit your completed assignment, save your Assignment as WK9Assgn2_LastName_Firstinitial

2. Then, click on Start Assignment near the top of the page. 3. Next, click on Upload File and select Submit Assignment for review.

BY DAY 7

SUBMISSION INFORMATION

9/23/24, 12:55 PM Week 9: Assignment 2

https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 2/5

Criteria Ratings Pts

10 pts

20 pts

10 pts

Organization of Write-up

10 to >6.0 pts Excellent All information organized in logical sequence; follows acceptable format and utilizes expected headings.

6 to >3.0 pts Good Information generally organized in logical sequence; follows acceptable format and utilizes expected headings.

3 to >0.0 pts Fair Errors in format; information intermittently organized. Headings are used some of the time.

0 pts Poor Errors in format; information disorganized. Headings are not used appropriately.

Thoroughness of History

20 to >15.0 pts Excellent Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information.

15 to >11.0 pts Good Documents most pertinent examination components.

11 to >7.0 pts Fair Documents some pertinent examination components.

7 to >0 pts Poor Physical examination cursory; misses several pertinent components.

History of Present Illness

10 to >6.0 pts Excellent Thoroughly documents all 8 aspects of HPI and pertinent other data relevant to chief complaint. Includes critical as well as supportive information.

6 to >4.0 pts Good Documents at least 6 aspects of the HPI and pertinent other data relevant to chief complaint. Includes critical information.

4 to >2.0 pts Fair Documents at least 4 aspects of HPI and some data pertinent to chief complaint. Lacks some critical information or rambling in history.

2 to >0 pts Poor Missing many aspects of HPI and pertinent data. Critical information missing.

Thoroughness of Physical Exam

10 to >7.0 pts Excellent Thoroughly documents all pertinent examination components for type of note.

7 to >4.0 pts Good Documents most pertinent examination components.

4 to >2.0 pts Fair Documents some pertinent examination components.

2 to >0 pts Poor Physical examination cursory; misses several pertinent components.

Diagnostic Reasoning

10 to >7.0 pts Excellent Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when

7 to >4.0 pts Good Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most

4 to >2.0 pts Fair Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders

2 to >0 pts Poor Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders

9/23/24, 12:55 PM Week 9: Assignment 2

https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 3/5

Criteria Ratings Pts

20 pts

10 pts

5 pts

ordering diagnostic tests.

secondary problems.

inappropriate diagnostic tests.

Treatment Plan/Patient Education

20 to >15.0 pts Excellent Treatment plan addresses all issues raised by diagnoses, excellent insight into patient’s needs. Medications prescribed are appropriate and full prescription is included. Evidence based decisions. Cost effective treatment.

15 to >10.0 pts Good Treatment plan addresses most issues raised by diagnoses. Medications prescribed are appropriate but include 1 or 2 error in writing prescription.

10 to >5.0 pts Fair Treatment plan fails to address most issues raised by diagnoses. Medications are inappropriate or include 3 or more errors in writing prescription.

5 to >0 pts Poor Minimal treatment plan addressed. Medications are inappropriate or poorly written prescription.

Patient Education / Follow Up / Reflection

10 to >8.0 pts Excellent Patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Follow up plan in appropriate and reflects acuity of illness. Reflection is thoughtful and in depth.

8 to >5.0 pts Good Patient education addresses most issues raised by diagnoses. Follow up plan is appropriate but lacks specifics Reflection is thoughtful and in depth.

5 to >3.0 pts Fair Patient education fails to address most issues raised by diagnoses. Follow up plan is lacking specifics or is inappropriate for patient acuity. Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.

3 to >0 pts Poor Minimal patient education addressed. Follow up plan is inappropriate Reflection is absent.

Written Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation. Professional language utilized

5 pts Excellent Uses correct grammar, spelling, and punctuation with no errors. Professional language utilized.

4 pts Good Contains a few (1- 2) grammar, spelling, and punctuation errors. Contains a few errors (1 or 2) in professional language use.

2 pts Fair Contains several (3-4) grammar, spelling, and punctuation errors. Contains several errors (3 -4) in professional language use.

0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Contains many errors in professional language use.

9/23/24, 12:55 PM Week 9: Assignment 2

https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 4/5

Total Points: 100

Criteria Ratings Pts

5 pts

Scholarly References and Clinical Practice Guidelines. The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Clinical practice guidelines are included if applicable.

5 pts Excellent Contains parenthetical/in-text citations and at least 3 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.

4 pts Good Contains parenthetical/in-text citations and at least 2 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.

2 pts Fair Contains parenthetical/in-text citations and at least 1 evidenced based reference less than 5 years old is listed. Clinical practice guidelines are not cited if applicable.

0 pts Poor Contains no parenthetical/in-text citations and 0 evidenced based references listed. Clinical practice guidelines are not cited if applicable.

9/23/24, 12:55 PM Week 9: Assignment 2

https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 5/5

WK9FocusedNote.docx

In clinical settings, patients often present with musculoskeletal conditions such as chronic back pain. Drugs are typically prescribed to help manage this type of pain for patients. There are many different pain medicines, and each one has benefits and risks. To add to the complexity, each patient may also have a slightly different response to a pain reliever. When over-the-counter medications do not address a patient’s pain, more powerful prescription pain relievers, such as opioids, can be effective but also sometimes have serious side effects. There is also a risk of addiction. More than 70,000 people died in 2017 from drug overdoses, and almost 68% involved a prescription or illicit opioid. Drug overdose deaths continue to increase in the United States (Centers for Disease Control and Prevention, n.d.).

For the advanced practice nurse, these statistics highlight the need to effectively screen for, diagnose, and manage opioid use. It is essential to carefully observe and watch for signs of drug abuse during patient evaluations. Because not all musculoskeletal conditions require narcotics, a thorough patient evaluation will help to ensure the development of an appropriate treatment plan with patient safety in mind.

This week, you will continue to engage with Meditrek, recording your clinical hours and patient encounters. You will also learn about evaluation and management of musculoskeletal conditions in the reading selections as well as conduct a patient evaluation of a patient from your practicum experience who has a musculoskeletal condition. Based on diagnostic and treatment options you identify for the patient, you will identify a primary diagnosis, as well as a treatment and management plan.

Reference Centers for Disease Control and Prevention (n.d.). CDC’s response to the opioid overdose epidemic. https://www.cdc.gov/opioids/

LEARNING OBJECTIVES

Students will:

· Describe clinical hours and patient encounters

· Formulate diagnoses for adult patients

· Justify adult patient treatment options

· Advocate health promotion and patient education strategies across the adult lifespan

· Synthesize the assessment and diagnosis of health conditions for a clinical patient

· Fowler, G. C. (2020). Pfenninger and Fowler's procedures for primary care (4th ed.). Elsevier.

· Chapter 174, “Shoulder Dislocations” (pp. 1163–1167)

· Chapter 175, “Ankle and Foot Splinting, Casting, and Taping” (pp. 1168–1175)

· Chapter 176, “Cast Immobilization and Upper Extremity Splinting” (pp. 1176–1185)

· Chapter 177, “Knee Braces” (pp. 1186–1192)

· Chapter 178, “Fracture Care” (pp. 1193–1211)

· Chapter 180, “Joint and Soft Tissue Aspiration and Injection (Arthrocentesis)” (pp. 1221–1239)

· Chapter 181, “Trigger-Point Injection” (pp. 1240–1244)

· Chapter 235, “Principles of X-Ray Interpretation” (pp. 1566–1575)

PRAC_6531_Episodic_Focused_Note_Template_Final1.docx

Master of Science in Nursing PRAC 6531: Primary Care of Adults Across the Lifespan Practicum

Episodic/Focus Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT "bad headache for 3 days”).

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 AA male). 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, Aleve 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 OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs 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 Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. 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.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, 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, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing 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: etc.).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A .

Differential Diagnoses (list a minimum of three 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.

P.

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 which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.