NSG550 Clinical Soap Note Questions

NSG550 Clinical Soap Note Questions
· Start early. There is a week where no weekly post is due in week 7. If that fits in your schedule, you might do your clinical note that week.
· Directions: Go to Content, then Resource, then find Clinical Note Guidelines.
· The directions direct you to have a cover page, a reference page, and 3 pages of content. The outline directs you of what to cover.
· Who can be your patient? Someone who is verbal and can give you a history. It could be, but does not have to be a patient. It could be a willing family member or friend. If it is a patient, be sure to get consent explaining this as a school project.
· Please do a full history and review of systems on your ‘patient.’
NSG550 Clinical Soap Note Questions
· The physical exam should include all non-invasive areas. Depending on the reason for visit, you may or may not complete a breast exam and genital exam.
· Note that the assessment sections and treatment sections are 35% of the paper grade. In the assessment section list your suspected diagnosis and differentials. Have rationale for each of them. In the treatment section (as in your weekly cases) add rationale, expected findings, and teaching for your diagnostics and treatments.
Each student will complete a clinical note utilizing the framework of a comprehensive health history and physical examination. The written assignment is documentation of the findings and should demonstrate application of course content and follow the criteria provided below. This should be in a charting format and no longer than 3 pages, excluding a title and reference page. Five points will be deducted for assignments longer than the stated criteria.
APA not required so single spacing is allowed. Mastering succinctness of communication, both written and verbal of clinical reasoning, is critical to the process of becoming a nurse practitioner.
Content Grade Percentage Choose a patient to perform the H and P; this person could be a family member or patient from your clinical practice. Only use initials when identifying the patient. 5% Chief Complaint and History of Present Illness 5% Past Medical and Surgical History 5% Medications and Allergies 5 % Family History 5% Social History 5% Review of Systems (include only subjective symptoms obtained from the health history –what did the patient say?) 15% Physical Examination (include only objective findings determined by the physical examination you completed). 15% Assessment and Plan (You can make one section with the Assessment/Plan or you can keep them as separate sections). Provide all possible diagnoses based upon clinical decision making listing the one with the highest probability first. Provide comprehensive treatment plan and communicate clinical reasoning; utilize theory from NSG500, 550, 530, and 533. Provide clinical support/citations.35% Provides references of peer reviewed, scholarly citations 5% Total 100% Criteria for this written assignment can be found on the next page below.
NSG550 Clinical Soap Note Questions
History—Subjective Data ID Age, gender, DOB CC Reason for seeking care-patient’s own words HPI O-onset L-location D-duration C-character A-aggravating/associated factors R-relieving factors T-temporal factors S-severity Medications, treatments PMH/PSH General health, surgeries, hospitalizations, illnesses, immunizations, medications, allergies, blood transfusions, emotional status/psychiatric history PERSONAL HISTORY Cultural background, marital status, occupation, economic resources, environment HEALTH HABITS Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins HEALTH MAINTENANCE Last PE; diagnostic tests (date, result, follow-up); self-exams (breast, genital, testicular); last Pap smear, mammogram FAMILY HISTORY (Parents, siblings, children) Cancer, DM, hypertension, heart disease, stroke REVIEW OF SYSTEMS GENERAL Fever, chills, malaise, fatigue/energy, night sweats, desired weight DIET Appetite, restrictions, vitamins, supplements SKIN, HAIR, NAILS Rash, eruptions, itching, pigment changes HEAD AND NECK Headaches, dizziness, head injuries, loss of consciousness EYES Blurring, double vision, visual changes, glasses, trauma, eye diseases EARS Hearing loss, pain, discharge, vertigo, tinnitus NOSE Congestion, nosebleeds, postnasal drip