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21.06.2025
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pedssoapnoteexample.docx
pedsihumanweek4.docx

pedssoapnoteexample.docx

Students must paste their SOAP note under the management plan section of the iHuman system.

Dear Student,

Please make sure to write your SOAP note directly in the Management Plan section within the iHuman platform. It is important that all work is completed within iHuman. Any Word document attachments will not be accepted or graded, so be sure to submit everything through the appropriate platform.

Thank you for your attention to this.*********************************

SUBJECTIVE (15 pts):

CC: “2-3 word description” (1 point)

HPI: **Must write as a paragraph. NO BULLET POINTS. See example. ((10 points)

All: (1 point)

PMH: (1 point)

FMH: (1 point)

MEDS: (1 point)

OBJECTIVE (15 pts): Only include the pertinent systems. Note that CV/Pulm should always be included in all PE.

VS: (1 point)

PE: (see example if needed) (10 points)

Diagnostic Test/labs done: (4 points)

Assessment (15 pts):

Primary Diagnosis & ICD code: (2 points) Rationale (4 points)

i. DDX#1 w ICD code and rational (3 points)

ii. DDX#2 w ICD code and rational (3 points)

iii. DDX#3 w ICD code and rational (3 points)

MEDICATION (10 pts) WRITE as a prescription. Review how to write a prescription.

MEDICATION NAME: (include proper name and strength)

SIG: (this is the directions)

DISP: (this is how many you are giving)

RF: (any refills)

PLAN: 20 points (ALL areas must be included.)

Appropriate Interventions & Referrals: (8 points) ** See example SOAP note if unclear** This section should discuss what you did for the patient during the visit. Key exams required that you did to arrive at the diagnosis. Referrals needed?

Tell me what you did w/ this child in the office (breakdown below; all areas must be included)

· -What Intervention(s)/ treatment(s) in office: (for example-02, sutures, teach to use crutches, Tylenol, (4 Points)

· -Screening tool(s) used: (1 Point)

· -Referral(s) w rational: (1 point) IF NONE, write NONE do not skip

· -Address modifiable risk factors: eg stop smoking, reduce screen time, etc (2 points)

Pt. education (5 points)- - Educate parent and patient about today’s visit/diagnosis/meds etc. Must list a minimum of 5 patient education regarding today’s visit.

1. Pt Ed #1

2. Pt Ed #2

3. Pt Ed #3

4. Pt Ed #4

5. Pt Ed #5

SDOH: address all 6 areas of social determinants of health (3 points)

1) Economic Stability-

2) Neighborhood-

3) Education-

4) Food Access-

5) Community and Social Context

6) Healthcare System: .

Health Promotion/Anticipatory guidance: (4 points)

Must list a minimum of 4 related to child’s age. Do not simply write f/u on vaccinations, be specific. Use your Bright Futures to help you with this area. * This is not pt education* See examples.

1) Health Promotion #1

2) Health Promotion #2

3) Health Promotion #3

4) Health Promotion #4

Follow-up: (5 points)

a. Timing/when: (1 points); Next WCV (1 pt)

b. Symptom to watch for that will prompt a return (red flags): (3points)

Office BILLING/VISIT CODE and CPT CODES (5 pts)

Clinical Guidelines: 5 points

a. Name of guidelines: (1 points)

b. What does the guidelines tell you to do, or how to make a diagnosis (4 points)

REFERENCES (USE APA)

REFERENCES: SUBJECTED TO UP TO 5 POINT DEDUCTION IF NOT CITED IN YOUR TEXT

Must have 3 and must show that it is cited within your text. Please understand that references provide the information necessary for readers to identify and retrieve each work cited in the text. If your references are not cited within your text, then points will be deducted.

**NO MAYO CLINIC, no pt. education websites, CDC should only be for stats. REFERENCES must be peer-reviewed literature. Please utilize the Walden Library. Use primary sources.

pedsihumanweek4.docx

i-Human Case Study: Evaluation and Management of EENT Conditions or respiratory conditions

A person touching a child's mouth Description automatically generated

Welcome to another i-Human Case Study. Take a moment to imagine a child and family you might meet. Based on the Learning Resources for this week, consider eye, ear, nose, and throat (EENT); and respiratory conditions you may identify frequently as a Family Nurse Practitioner and those that may be more unusual. Also consider what aspects of the exam process might be more challenging for you—assessing, evaluating, providing multiple diagnoses, treatments, or offering the patient and family management advice. Work to be mindful of how to take best advantage of the simulated i-Human exam to prepare for pediatric patients with EENT and respiratory conditions.

Resources

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

WEEKLY RESOURCES

To prepare:

· Review this week’s Learning Resources and consider how to apply knowledge of EENT and respiratory conditions and understanding of socio-cultural family needs in assessing, diagnosing, and treating pediatric patients.

· Access i-Human Patients from this week’s Learning Resources and review the i-Human Case Study. Based on the provided patient information, think about the health history you would need to collect from the patient.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. Reflect on how the results would be used to make a diagnosis.

· Identify 3–5 possible conditions that may be considered in a differential diagnosis for the patient.

· Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.

· Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with EENT conditions and their families.

Assignment:

As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.

By Day 7 of Week 4

Complete your Assignment in i-Human.

You will access i-Human from the Access i-Human link located in the Start Here module .

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.

1. To submit your completed assignment, save your Assignment as WK4Assgn+last name+first initial.

2. Then, click on Start Assignment near the top of the page.

3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6541_Week4_Assignment_Rubric

NRNP_6541_Week4_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeCOMPLETION of the iHuman: Students must complete the required sections: • PE • key findings • differential diagnoses • test summary.	10 to >6.0 ptsProficientStudent successfully completed all required sections in iHuman. 6 to >2.0 ptsCompetentStudent missed completing 1-2 of the required sections. 2 to >0 ptsNoviceStudent does not complete the iHuman required components.	10 pts
This criterion is linked to a Learning OutcomeSUBJECTIVE: Complete HPI including all 8 aspects and pertinent information related to chief complaint, including the pertinent positives & negatives	15 to >9.0 ptsProficient• Clearly written chief complaint • HPI well written including all aspects of OLDCARTS/LOCATES • Includes pertinent positives & negatives 9 to >3.0 ptsCompetent• Clearly written chief complaint • Misses 1-2 key components from the history • Missing pertinent positives and negatives 3 to >0 ptsNovice• Poorly written HPI • Student includes PE findings • Lacks basic history taking • Missing pertinent positives and negatives	15 pts
This criterion is linked to a Learning OutcomeOBJECTIVE: Physical exam includes appropriate areas based on the pertinent history (subjective).	15 to >9.0 ptsProficient• Thoroughly documents all pertinent examination components for type of note • Does not include unnecessary systems in the documentation • Utilizes the correct screening tools 9 to >3.0 ptsCompetent• Documents most pertinent examination components. • Misses 1-3 components • Does not include unnecessary systems in the documentation • Utilizes the correct screening tools 3 to >0 ptsNovice• Physical examination cursory • misses several pertinent components • Includes unnecessary systems in the documentation • Does not utilize the screening tools	15 pts
This criterion is linked to a Learning OutcomeASSESSMENT: Primary diagnosis and differential diagnoses are identified and supported by rationales; correct ICD codes provided, and appropriate diagnostic tests are ordered.	15 to >9.0 ptsProficient• Identifies the primary diagnosis with rationale and the correct ICD • 3 differential diagnoses with ICD codes are supported by findings and ruled out • Appropriate tests ordered and results documented • Rationale for differential diagnoses provided by scholarly resources 9 to >3.0 ptsCompetent• Identifies the primary diagnosis with rationale and the correct ICD • 3 differential diagnoses are identified but 1-2 are not supported by findings. ICD codes included • Missing <1-2 appropriate tests ordered, and results documented • Rationale for differential diagnoses provided by scholarly resources 3 to >0 ptsNovice• Incorrect primary does not provide a rationale and incorrect ICD code • <3 differential diagnoses identified, or differential diagnoses not supported by findings • Inappropriate tests ordered • Scholarly resources not provided or do not support differential diagnoses	15 pts
This criterion is linked to a Learning OutcomeMEDICATION: Ordered (including over the counter) are appropriate, evidenced based, written as a complete prescription.	10 to >6.0 ptsProficient• Student appropriately writes the correct medication as a prescription • Student appropriately calculates the correct doses and route 6 to >2.0 ptsCompetent• Student misses 1-2 components of medication order • Student appropriately calculates the correct doses and route 2 to >0 ptsNovice• Student identifies the incorrect medication • Student does not appropriately calculate the correct doses and route	10 pts
This criterion is linked to a Learning OutcomePLAN: Comprehensive plan to address the diagnosis should include the following: • Appropriate interventions & referrals (if needed) • Pt education • SDOH • Health promotion/anticipatory guidance	20 to >12.0 ptsProficient• Clearly written plan covering all critical components proper intervention, including referrals for the patient’s final diagnosis • Student addresses 6 components of SDOH • Student includes 4 health maintenance • Comprehensive patient education is included related to current health visit, must list 5. • Supported 3 by peer-reviewed literature 12 to >8.0 ptsCompetent• Well written plan but may be missing 1-2 key issues critical to patient’s diagnosis • Some aspects of SDOH are addressed • Some aspects of Health Promotion/anticipatory guidance are addressed. • Patient education is present but missing 1 or 2 key pieces of information • Supported by only 2 peer reviewed literature 8 to >0 ptsNovice• Poorly written plan. May be missing 3 or more key issues that are critical to patient's diagnosis • There are missing aspects of SDOH • There are missing aspects health promotion anticipatory guidance • Patient education is missing many aspects related to current visit • Supported by less than 2 peer reviewed literature	20 pts
This criterion is linked to a Learning OutcomeFOLLOW-UP: Instructions	5 to >3.0 ptsProficientFollow up instructions are complete and include time to next visit and specific symptoms to prompt a return visit sooner. 3 to >1.0 ptsCompetent• Follow up instructions are generally complete but missing 1 or 2 aspects • Symptoms that would prompt a return visit sooner are included but some are missing 1 to >0 ptsNovice• Follow up instructions are missing important timing aspects • Symptoms prompting return visit sooner are incomplete or missing	5 pts
This criterion is linked to a Learning OutcomeOFFICE BILLING/VISIT CODE: CPT CODES	5 to >3.0 ptsProficient• Student identifies the correct office billing code • Student identifies the correct CPT codes 3 to >1.0 ptsCompetent• Student does not correctly identify the correct office billing code • Student does not correctly identify the correct CPT codes 1 to >0 ptsNoviceStudent does not address the billing and CPT codes.	5 pts
This criterion is linked to a Learning OutcomeClinical Guidelines	5 to >3.0 ptsProficientStudent identifies the clinical guidelines utilized and rationale. 3 to >1.0 ptsCompetentStudent identifies the clinical guidelines but does not provide a rationale. 1 to >0 ptsNoviceStudent does not address the clinical guidelines.	5 pts

image1.jpeg

pedsihumanweek4.docx

i-Human Case Study: Evaluation and Management of EENT Conditions or respiratory conditions

A person touching a child's mouth Description automatically generated

Resources

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

WEEKLY RESOURCES

To prepare:

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. Reflect on how the results would be used to make a diagnosis.

· Identify 3–5 possible conditions that may be considered in a differential diagnosis for the patient.

· Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.

· Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with EENT conditions and their families.

Assignment:

As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.

By Day 7 of Week 4

Complete your Assignment in i-Human.

You will access i-Human from the Access i-Human link located in the Start Here module .

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.

1. To submit your completed assignment, save your Assignment as WK4Assgn+last name+first initial.

2. Then, click on Start Assignment near the top of the page.

3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6541_Week4_Assignment_Rubric

NRNP_6541_Week4_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeCOMPLETION of the iHuman: Students must complete the required sections: • PE • key findings • differential diagnoses • test summary.	10 to >6.0 ptsProficientStudent successfully completed all required sections in iHuman. 6 to >2.0 ptsCompetentStudent missed completing 1-2 of the required sections. 2 to >0 ptsNoviceStudent does not complete the iHuman required components.	10 pts
This criterion is linked to a Learning OutcomeSUBJECTIVE: Complete HPI including all 8 aspects and pertinent information related to chief complaint, including the pertinent positives & negatives	15 to >9.0 ptsProficient• Clearly written chief complaint • HPI well written including all aspects of OLDCARTS/LOCATES • Includes pertinent positives & negatives 9 to >3.0 ptsCompetent• Clearly written chief complaint • Misses 1-2 key components from the history • Missing pertinent positives and negatives 3 to >0 ptsNovice• Poorly written HPI • Student includes PE findings • Lacks basic history taking • Missing pertinent positives and negatives	15 pts
This criterion is linked to a Learning OutcomeOBJECTIVE: Physical exam includes appropriate areas based on the pertinent history (subjective).	15 to >9.0 ptsProficient• Thoroughly documents all pertinent examination components for type of note • Does not include unnecessary systems in the documentation • Utilizes the correct screening tools 9 to >3.0 ptsCompetent• Documents most pertinent examination components. • Misses 1-3 components • Does not include unnecessary systems in the documentation • Utilizes the correct screening tools 3 to >0 ptsNovice• Physical examination cursory • misses several pertinent components • Includes unnecessary systems in the documentation • Does not utilize the screening tools	15 pts
This criterion is linked to a Learning OutcomeASSESSMENT: Primary diagnosis and differential diagnoses are identified and supported by rationales; correct ICD codes provided, and appropriate diagnostic tests are ordered.	15 to >9.0 ptsProficient• Identifies the primary diagnosis with rationale and the correct ICD • 3 differential diagnoses with ICD codes are supported by findings and ruled out • Appropriate tests ordered and results documented • Rationale for differential diagnoses provided by scholarly resources 9 to >3.0 ptsCompetent• Identifies the primary diagnosis with rationale and the correct ICD • 3 differential diagnoses are identified but 1-2 are not supported by findings. ICD codes included • Missing <1-2 appropriate tests ordered, and results documented • Rationale for differential diagnoses provided by scholarly resources 3 to >0 ptsNovice• Incorrect primary does not provide a rationale and incorrect ICD code • <3 differential diagnoses identified, or differential diagnoses not supported by findings • Inappropriate tests ordered • Scholarly resources not provided or do not support differential diagnoses	15 pts
This criterion is linked to a Learning OutcomeMEDICATION: Ordered (including over the counter) are appropriate, evidenced based, written as a complete prescription.	10 to >6.0 ptsProficient• Student appropriately writes the correct medication as a prescription • Student appropriately calculates the correct doses and route 6 to >2.0 ptsCompetent• Student misses 1-2 components of medication order • Student appropriately calculates the correct doses and route 2 to >0 ptsNovice• Student identifies the incorrect medication • Student does not appropriately calculate the correct doses and route	10 pts
This criterion is linked to a Learning OutcomePLAN: Comprehensive plan to address the diagnosis should include the following: • Appropriate interventions & referrals (if needed) • Pt education • SDOH • Health promotion/anticipatory guidance	20 to >12.0 ptsProficient• Clearly written plan covering all critical components proper intervention, including referrals for the patient’s final diagnosis • Student addresses 6 components of SDOH • Student includes 4 health maintenance • Comprehensive patient education is included related to current health visit, must list 5. • Supported 3 by peer-reviewed literature 12 to >8.0 ptsCompetent• Well written plan but may be missing 1-2 key issues critical to patient’s diagnosis • Some aspects of SDOH are addressed • Some aspects of Health Promotion/anticipatory guidance are addressed. • Patient education is present but missing 1 or 2 key pieces of information • Supported by only 2 peer reviewed literature 8 to >0 ptsNovice• Poorly written plan. May be missing 3 or more key issues that are critical to patient's diagnosis • There are missing aspects of SDOH • There are missing aspects health promotion anticipatory guidance • Patient education is missing many aspects related to current visit • Supported by less than 2 peer reviewed literature	20 pts
This criterion is linked to a Learning OutcomeFOLLOW-UP: Instructions	5 to >3.0 ptsProficientFollow up instructions are complete and include time to next visit and specific symptoms to prompt a return visit sooner. 3 to >1.0 ptsCompetent• Follow up instructions are generally complete but missing 1 or 2 aspects • Symptoms that would prompt a return visit sooner are included but some are missing 1 to >0 ptsNovice• Follow up instructions are missing important timing aspects • Symptoms prompting return visit sooner are incomplete or missing	5 pts
This criterion is linked to a Learning OutcomeOFFICE BILLING/VISIT CODE: CPT CODES	5 to >3.0 ptsProficient• Student identifies the correct office billing code • Student identifies the correct CPT codes 3 to >1.0 ptsCompetent• Student does not correctly identify the correct office billing code • Student does not correctly identify the correct CPT codes 1 to >0 ptsNoviceStudent does not address the billing and CPT codes.	5 pts
This criterion is linked to a Learning OutcomeClinical Guidelines	5 to >3.0 ptsProficientStudent identifies the clinical guidelines utilized and rationale. 3 to >1.0 ptsCompetentStudent identifies the clinical guidelines but does not provide a rationale. 1 to >0 ptsNoviceStudent does not address the clinical guidelines.	5 pts

image1.jpeg

pedssoapnoteexample.docx

Students must paste their SOAP note under the management plan section of the iHuman system.

Dear Student,

Thank you for your attention to this.*********************************

SUBJECTIVE (15 pts):

CC: “2-3 word description” (1 point)

HPI: **Must write as a paragraph. NO BULLET POINTS. See example. ((10 points)

All: (1 point)

PMH: (1 point)

FMH: (1 point)

MEDS: (1 point)

OBJECTIVE (15 pts): Only include the pertinent systems. Note that CV/Pulm should always be included in all PE.

VS: (1 point)

PE: (see example if needed) (10 points)

Diagnostic Test/labs done: (4 points)

Assessment (15 pts):

Primary Diagnosis & ICD code: (2 points) Rationale (4 points)

i. DDX#1 w ICD code and rational (3 points)

ii. DDX#2 w ICD code and rational (3 points)

iii. DDX#3 w ICD code and rational (3 points)

MEDICATION (10 pts) WRITE as a prescription. Review how to write a prescription.

MEDICATION NAME: (include proper name and strength)

SIG: (this is the directions)

DISP: (this is how many you are giving)

RF: (any refills)

PLAN: 20 points (ALL areas must be included.)

Tell me what you did w/ this child in the office (breakdown below; all areas must be included)

· -What Intervention(s)/ treatment(s) in office: (for example-02, sutures, teach to use crutches, Tylenol, (4 Points)

· -Screening tool(s) used: (1 Point)

· -Referral(s) w rational: (1 point) IF NONE, write NONE do not skip

· -Address modifiable risk factors: eg stop smoking, reduce screen time, etc (2 points)

Pt. education (5 points)- - Educate parent and patient about today’s visit/diagnosis/meds etc. Must list a minimum of 5 patient education regarding today’s visit.

1. Pt Ed #1

2. Pt Ed #2

3. Pt Ed #3

4. Pt Ed #4

5. Pt Ed #5

SDOH: address all 6 areas of social determinants of health (3 points)

1) Economic Stability-

2) Neighborhood-

3) Education-

4) Food Access-

5) Community and Social Context

6) Healthcare System: .

Health Promotion/Anticipatory guidance: (4 points)

1) Health Promotion #1

2) Health Promotion #2

3) Health Promotion #3

4) Health Promotion #4

Follow-up: (5 points)

a. Timing/when: (1 points); Next WCV (1 pt)

b. Symptom to watch for that will prompt a return (red flags): (3points)

Office BILLING/VISIT CODE and CPT CODES (5 pts)

Clinical Guidelines: 5 points

a. Name of guidelines: (1 points)

b. What does the guidelines tell you to do, or how to make a diagnosis (4 points)

REFERENCES (USE APA)

REFERENCES: SUBJECTED TO UP TO 5 POINT DEDUCTION IF NOT CITED IN YOUR TEXT

**NO MAYO CLINIC, no pt. education websites, CDC should only be for stats. REFERENCES must be peer-reviewed literature. Please utilize the Walden Library. Use primary sources.

pedsihumanweek4.docx

i-Human Case Study: Evaluation and Management of EENT Conditions or respiratory conditions

A person touching a child's mouth Description automatically generated

Resources

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

WEEKLY RESOURCES

To prepare:

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. Reflect on how the results would be used to make a diagnosis.

· Identify 3–5 possible conditions that may be considered in a differential diagnosis for the patient.

· Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.

· Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with EENT conditions and their families.

Assignment:

As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.

By Day 7 of Week 4

Complete your Assignment in i-Human.

You will access i-Human from the Access i-Human link located in the Start Here module .

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.

1. To submit your completed assignment, save your Assignment as WK4Assgn+last name+first initial.

2. Then, click on Start Assignment near the top of the page.

3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6541_Week4_Assignment_Rubric

NRNP_6541_Week4_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeCOMPLETION of the iHuman: Students must complete the required sections: • PE • key findings • differential diagnoses • test summary.	10 to >6.0 ptsProficientStudent successfully completed all required sections in iHuman. 6 to >2.0 ptsCompetentStudent missed completing 1-2 of the required sections. 2 to >0 ptsNoviceStudent does not complete the iHuman required components.	10 pts
This criterion is linked to a Learning OutcomeSUBJECTIVE: Complete HPI including all 8 aspects and pertinent information related to chief complaint, including the pertinent positives & negatives	15 to >9.0 ptsProficient• Clearly written chief complaint • HPI well written including all aspects of OLDCARTS/LOCATES • Includes pertinent positives & negatives 9 to >3.0 ptsCompetent• Clearly written chief complaint • Misses 1-2 key components from the history • Missing pertinent positives and negatives 3 to >0 ptsNovice• Poorly written HPI • Student includes PE findings • Lacks basic history taking • Missing pertinent positives and negatives	15 pts
This criterion is linked to a Learning OutcomeOBJECTIVE: Physical exam includes appropriate areas based on the pertinent history (subjective).	15 to >9.0 ptsProficient• Thoroughly documents all pertinent examination components for type of note • Does not include unnecessary systems in the documentation • Utilizes the correct screening tools 9 to >3.0 ptsCompetent• Documents most pertinent examination components. • Misses 1-3 components • Does not include unnecessary systems in the documentation • Utilizes the correct screening tools 3 to >0 ptsNovice• Physical examination cursory • misses several pertinent components • Includes unnecessary systems in the documentation • Does not utilize the screening tools	15 pts
This criterion is linked to a Learning OutcomeASSESSMENT: Primary diagnosis and differential diagnoses are identified and supported by rationales; correct ICD codes provided, and appropriate diagnostic tests are ordered.	15 to >9.0 ptsProficient• Identifies the primary diagnosis with rationale and the correct ICD • 3 differential diagnoses with ICD codes are supported by findings and ruled out • Appropriate tests ordered and results documented • Rationale for differential diagnoses provided by scholarly resources 9 to >3.0 ptsCompetent• Identifies the primary diagnosis with rationale and the correct ICD • 3 differential diagnoses are identified but 1-2 are not supported by findings. ICD codes included • Missing <1-2 appropriate tests ordered, and results documented • Rationale for differential diagnoses provided by scholarly resources 3 to >0 ptsNovice• Incorrect primary does not provide a rationale and incorrect ICD code • <3 differential diagnoses identified, or differential diagnoses not supported by findings • Inappropriate tests ordered • Scholarly resources not provided or do not support differential diagnoses	15 pts
This criterion is linked to a Learning OutcomeMEDICATION: Ordered (including over the counter) are appropriate, evidenced based, written as a complete prescription.	10 to >6.0 ptsProficient• Student appropriately writes the correct medication as a prescription • Student appropriately calculates the correct doses and route 6 to >2.0 ptsCompetent• Student misses 1-2 components of medication order • Student appropriately calculates the correct doses and route 2 to >0 ptsNovice• Student identifies the incorrect medication • Student does not appropriately calculate the correct doses and route	10 pts
This criterion is linked to a Learning OutcomePLAN: Comprehensive plan to address the diagnosis should include the following: • Appropriate interventions & referrals (if needed) • Pt education • SDOH • Health promotion/anticipatory guidance	20 to >12.0 ptsProficient• Clearly written plan covering all critical components proper intervention, including referrals for the patient’s final diagnosis • Student addresses 6 components of SDOH • Student includes 4 health maintenance • Comprehensive patient education is included related to current health visit, must list 5. • Supported 3 by peer-reviewed literature 12 to >8.0 ptsCompetent• Well written plan but may be missing 1-2 key issues critical to patient’s diagnosis • Some aspects of SDOH are addressed • Some aspects of Health Promotion/anticipatory guidance are addressed. • Patient education is present but missing 1 or 2 key pieces of information • Supported by only 2 peer reviewed literature 8 to >0 ptsNovice• Poorly written plan. May be missing 3 or more key issues that are critical to patient's diagnosis • There are missing aspects of SDOH • There are missing aspects health promotion anticipatory guidance • Patient education is missing many aspects related to current visit • Supported by less than 2 peer reviewed literature	20 pts
This criterion is linked to a Learning OutcomeFOLLOW-UP: Instructions	5 to >3.0 ptsProficientFollow up instructions are complete and include time to next visit and specific symptoms to prompt a return visit sooner. 3 to >1.0 ptsCompetent• Follow up instructions are generally complete but missing 1 or 2 aspects • Symptoms that would prompt a return visit sooner are included but some are missing 1 to >0 ptsNovice• Follow up instructions are missing important timing aspects • Symptoms prompting return visit sooner are incomplete or missing	5 pts
This criterion is linked to a Learning OutcomeOFFICE BILLING/VISIT CODE: CPT CODES	5 to >3.0 ptsProficient• Student identifies the correct office billing code • Student identifies the correct CPT codes 3 to >1.0 ptsCompetent• Student does not correctly identify the correct office billing code • Student does not correctly identify the correct CPT codes 1 to >0 ptsNoviceStudent does not address the billing and CPT codes.	5 pts
This criterion is linked to a Learning OutcomeClinical Guidelines	5 to >3.0 ptsProficientStudent identifies the clinical guidelines utilized and rationale. 3 to >1.0 ptsCompetentStudent identifies the clinical guidelines but does not provide a rationale. 1 to >0 ptsNoviceStudent does not address the clinical guidelines.	5 pts

image1.jpeg

pedssoapnoteexample.docx

Students must paste their SOAP note under the management plan section of the iHuman system.

Dear Student,

Thank you for your attention to this.*********************************

SUBJECTIVE (15 pts):

CC: “2-3 word description” (1 point)

HPI: **Must write as a paragraph. NO BULLET POINTS. See example. ((10 points)

All: (1 point)

PMH: (1 point)

FMH: (1 point)

MEDS: (1 point)

OBJECTIVE (15 pts): Only include the pertinent systems. Note that CV/Pulm should always be included in all PE.

VS: (1 point)

PE: (see example if needed) (10 points)

Diagnostic Test/labs done: (4 points)

Assessment (15 pts):

Primary Diagnosis & ICD code: (2 points) Rationale (4 points)

i. DDX#1 w ICD code and rational (3 points)

ii. DDX#2 w ICD code and rational (3 points)

iii. DDX#3 w ICD code and rational (3 points)

MEDICATION (10 pts) WRITE as a prescription. Review how to write a prescription.

MEDICATION NAME: (include proper name and strength)

SIG: (this is the directions)

DISP: (this is how many you are giving)

RF: (any refills)

PLAN: 20 points (ALL areas must be included.)

Tell me what you did w/ this child in the office (breakdown below; all areas must be included)

· -What Intervention(s)/ treatment(s) in office: (for example-02, sutures, teach to use crutches, Tylenol, (4 Points)

· -Screening tool(s) used: (1 Point)

· -Referral(s) w rational: (1 point) IF NONE, write NONE do not skip

· -Address modifiable risk factors: eg stop smoking, reduce screen time, etc (2 points)

Pt. education (5 points)- - Educate parent and patient about today’s visit/diagnosis/meds etc. Must list a minimum of 5 patient education regarding today’s visit.

1. Pt Ed #1

2. Pt Ed #2

3. Pt Ed #3

4. Pt Ed #4

5. Pt Ed #5

SDOH: address all 6 areas of social determinants of health (3 points)

1) Economic Stability-

2) Neighborhood-

3) Education-

4) Food Access-

5) Community and Social Context

6) Healthcare System: .

Health Promotion/Anticipatory guidance: (4 points)

1) Health Promotion #1

2) Health Promotion #2

3) Health Promotion #3

4) Health Promotion #4

Follow-up: (5 points)

a. Timing/when: (1 points); Next WCV (1 pt)

b. Symptom to watch for that will prompt a return (red flags): (3points)

Office BILLING/VISIT CODE and CPT CODES (5 pts)

Clinical Guidelines: 5 points

a. Name of guidelines: (1 points)

b. What does the guidelines tell you to do, or how to make a diagnosis (4 points)

REFERENCES (USE APA)

REFERENCES: SUBJECTED TO UP TO 5 POINT DEDUCTION IF NOT CITED IN YOUR TEXT

**NO MAYO CLINIC, no pt. education websites, CDC should only be for stats. REFERENCES must be peer-reviewed literature. Please utilize the Walden Library. Use primary sources.

pedsihumanweek4.docx

i-Human Case Study: Evaluation and Management of EENT Conditions or respiratory conditions

A person touching a child's mouth Description automatically generated

Resources

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

WEEKLY RESOURCES

To prepare:

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. Reflect on how the results would be used to make a diagnosis.

· Identify 3–5 possible conditions that may be considered in a differential diagnosis for the patient.

· Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.

· Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with EENT conditions and their families.

Assignment:

As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.

By Day 7 of Week 4

Complete your Assignment in i-Human.

You will access i-Human from the Access i-Human link located in the Start Here module .

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.

1. To submit your completed assignment, save your Assignment as WK4Assgn+last name+first initial.

2. Then, click on Start Assignment near the top of the page.

3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6541_Week4_Assignment_Rubric

NRNP_6541_Week4_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeCOMPLETION of the iHuman: Students must complete the required sections: • PE • key findings • differential diagnoses • test summary.	10 to >6.0 ptsProficientStudent successfully completed all required sections in iHuman. 6 to >2.0 ptsCompetentStudent missed completing 1-2 of the required sections. 2 to >0 ptsNoviceStudent does not complete the iHuman required components.	10 pts
This criterion is linked to a Learning OutcomeSUBJECTIVE: Complete HPI including all 8 aspects and pertinent information related to chief complaint, including the pertinent positives & negatives	15 to >9.0 ptsProficient• Clearly written chief complaint • HPI well written including all aspects of OLDCARTS/LOCATES • Includes pertinent positives & negatives 9 to >3.0 ptsCompetent• Clearly written chief complaint • Misses 1-2 key components from the history • Missing pertinent positives and negatives 3 to >0 ptsNovice• Poorly written HPI • Student includes PE findings • Lacks basic history taking • Missing pertinent positives and negatives	15 pts
This criterion is linked to a Learning OutcomeOBJECTIVE: Physical exam includes appropriate areas based on the pertinent history (subjective).	15 to >9.0 ptsProficient• Thoroughly documents all pertinent examination components for type of note • Does not include unnecessary systems in the documentation • Utilizes the correct screening tools 9 to >3.0 ptsCompetent• Documents most pertinent examination components. • Misses 1-3 components • Does not include unnecessary systems in the documentation • Utilizes the correct screening tools 3 to >0 ptsNovice• Physical examination cursory • misses several pertinent components • Includes unnecessary systems in the documentation • Does not utilize the screening tools	15 pts
This criterion is linked to a Learning OutcomeASSESSMENT: Primary diagnosis and differential diagnoses are identified and supported by rationales; correct ICD codes provided, and appropriate diagnostic tests are ordered.	15 to >9.0 ptsProficient• Identifies the primary diagnosis with rationale and the correct ICD • 3 differential diagnoses with ICD codes are supported by findings and ruled out • Appropriate tests ordered and results documented • Rationale for differential diagnoses provided by scholarly resources 9 to >3.0 ptsCompetent• Identifies the primary diagnosis with rationale and the correct ICD • 3 differential diagnoses are identified but 1-2 are not supported by findings. ICD codes included • Missing <1-2 appropriate tests ordered, and results documented • Rationale for differential diagnoses provided by scholarly resources 3 to >0 ptsNovice• Incorrect primary does not provide a rationale and incorrect ICD code • <3 differential diagnoses identified, or differential diagnoses not supported by findings • Inappropriate tests ordered • Scholarly resources not provided or do not support differential diagnoses	15 pts
This criterion is linked to a Learning OutcomeMEDICATION: Ordered (including over the counter) are appropriate, evidenced based, written as a complete prescription.	10 to >6.0 ptsProficient• Student appropriately writes the correct medication as a prescription • Student appropriately calculates the correct doses and route 6 to >2.0 ptsCompetent• Student misses 1-2 components of medication order • Student appropriately calculates the correct doses and route 2 to >0 ptsNovice• Student identifies the incorrect medication • Student does not appropriately calculate the correct doses and route	10 pts
This criterion is linked to a Learning OutcomePLAN: Comprehensive plan to address the diagnosis should include the following: • Appropriate interventions & referrals (if needed) • Pt education • SDOH • Health promotion/anticipatory guidance	20 to >12.0 ptsProficient• Clearly written plan covering all critical components proper intervention, including referrals for the patient’s final diagnosis • Student addresses 6 components of SDOH • Student includes 4 health maintenance • Comprehensive patient education is included related to current health visit, must list 5. • Supported 3 by peer-reviewed literature 12 to >8.0 ptsCompetent• Well written plan but may be missing 1-2 key issues critical to patient’s diagnosis • Some aspects of SDOH are addressed • Some aspects of Health Promotion/anticipatory guidance are addressed. • Patient education is present but missing 1 or 2 key pieces of information • Supported by only 2 peer reviewed literature 8 to >0 ptsNovice• Poorly written plan. May be missing 3 or more key issues that are critical to patient's diagnosis • There are missing aspects of SDOH • There are missing aspects health promotion anticipatory guidance • Patient education is missing many aspects related to current visit • Supported by less than 2 peer reviewed literature	20 pts
This criterion is linked to a Learning OutcomeFOLLOW-UP: Instructions	5 to >3.0 ptsProficientFollow up instructions are complete and include time to next visit and specific symptoms to prompt a return visit sooner. 3 to >1.0 ptsCompetent• Follow up instructions are generally complete but missing 1 or 2 aspects • Symptoms that would prompt a return visit sooner are included but some are missing 1 to >0 ptsNovice• Follow up instructions are missing important timing aspects • Symptoms prompting return visit sooner are incomplete or missing	5 pts
This criterion is linked to a Learning OutcomeOFFICE BILLING/VISIT CODE: CPT CODES	5 to >3.0 ptsProficient• Student identifies the correct office billing code • Student identifies the correct CPT codes 3 to >1.0 ptsCompetent• Student does not correctly identify the correct office billing code • Student does not correctly identify the correct CPT codes 1 to >0 ptsNoviceStudent does not address the billing and CPT codes.	5 pts
This criterion is linked to a Learning OutcomeClinical Guidelines	5 to >3.0 ptsProficientStudent identifies the clinical guidelines utilized and rationale. 3 to >1.0 ptsCompetentStudent identifies the clinical guidelines but does not provide a rationale. 1 to >0 ptsNoviceStudent does not address the clinical guidelines.	5 pts

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other Questions(10)