DIRECT CARE PROJECT PART 1ASSESSMENT AND DIAGNOSISDirectio

DIRECT CARE PROJECT PART 1
ASSESSMENT AND DIAGNOSIS
Directions: Prior to completing this template, carefully review
Week 2: Direct Care Part 1 directions and all rubric
requirements.
Assessment of Certification, Patient Outcomes, and Leadership
1. State the clinical certification and target population that were
approved by your instructor in the Week 2: Direct Care Part 1
Assessment and Diagnosis Check-In.
a. Clinical certification
PCCN
b. Target population including setting
Nurses who provide direct care to acutely ill adult patients
regardless of their physical location. My current unit is a
MSPCU floor.
2. Discuss why this clinical certification was selected in
relationship to the selected setting.
3. Describe the criteria for selected clinical certification
a. Process to obtain clinical certification
b. Cost of application and testing
c. Requirements prior to certification
d. Examination description

e. Renewal time and process
f. Required items for renewal
4. Provide APA reference for one peer-reviewed scholarly
professional nursing journal article connecting patient
outcomes, clinical certification, and leadership skills. See
reference criteria under directions and include Permalink.
5. Summary of article (one to two paragraphs)
6. How could patient outcomes in the selected setting be
improved by certified nurses?
7. How can clinical certification impact leadership skills in the
selected setting?
Problem Diagnosis Statement
Write a diagnosis based on the problem of knowledge deficit of
certifications. Fill in the blanks below.
Example: Knowledge deficit r/t CNOR certification among
operating room nurses (target population and setting) as
manifested by wrong site surgeries (patient outcomes)
Knowledge deficit r/t __________________certification among
__________(target population and setting) as manifested by
___________________(patient outcomes).

Title:
Documentation of problem based assessment of the
musculoskeletal system.
Purpose of Assignment:
Learning the required components of documenting a problem
based subjective and objective assessment of musculoskeletal
system. Identify abnormal findings.
Course Competency:
Demonstrate physical examination skills of the skin, hair, nails,
and musculoskeletal system.
Instructions:
Content: Use of three sections:
· Subjective
· Objective
· Actual or potential risk factors for the client based on the

assessment findings with description or reason for selection of
them.
Format:
· Standard American English (correct grammar, punctuation,
etc.)
Resources:
Chapter 5: SOAP Notes: The subjective and objective portion
only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-
Book]. Retrieved from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.
com/login.aspx?direct=true&db=nlebk&AN=495456&site=eds-
live&ebv=EB&ppid=pp_91
Smith, L. S. (2001, September). Documentation do’s and don’ts.
Nursing, 31(9), 30. Retrieved from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.
com/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-
live
Documentation Grading Rubric- 10 possible points
Levels of Achievement
Criteria
Emerging
Competence
Proficiency
Mastery
Subjective
(4 Pts)
Missing components such as biographic data, medications, or
allergies. Symptoms analysis is incomplete. May contain
objective data.
Basic biographic data provided. Medications and allergies

included. Symptoms analysis incomplete. Lacking detail. No
objective data.
Basic biographic data provided. Included list of medi cations and
allergies. Symptoms analysis: PQRSTU completed. Lacking
detail. No objective data. Information is solely what “client”
provided.
Basic biographic data provided. Included list of medications and
allergies. Symptoms analysis: PQRSTU completed. Detailed. No
objective data. Information is solely what “client” provided.
Points: 1
Points: 2
Points: 3
Points: 4
Objective
(4 Pts)
Missing components of assessment for particular system. May
contain subjective data. May have signs of bias or explanation
of findings. May have included words such as “normal”,
“appropriate”,
“okay”, and “good”.
Includes all components of assessment for particular system.
Lacks detail. Uses words such as “normal”, “appropriate”, or
“good”. Contains all objective informatio n. May have signs of
bias or explanation of findings.
Avoided use of words such as “normal”, “appropriate”, or
“good”. No bias or explanation for findings evident Contains
all objective information
Detailed information provided. Avoided use of words such as
“normal”, “appropriate”, or “good”. No bias or explanation for
findings evident. All objective information
Points: 1

Points: 2
Points: 3
Points: 4
Actual or Potential Risk Factors
(2 pts)
Lists one to two actual or potential risk factors for the client
based on the assessment findings with no description or reason
for selection of them. Failure to provide any potential or actual
risk factors will result in zero points for this criterion.
Brief description of one or two actual or potential risk factors
for the client based on assessment findings with description or
reason for selection of them.
Limited description of two actual or potential risk factors for
the client based on the assessment findings with description or
reason for selection of them.
Comprehensive, detailed description of two actual or potential
risk factors for the client based on the assessment findings with
description or reason for selection of them.
Points: 0.5
Points: 1
Points: 1.5
Points: 2
1
MHC 610 Final Project Part Three Guidelines and Rubric:
Treatment Plan
Overview

The final project for this course is the creation of a treatment
plan, also known as a comprehensive case conceptualization.
You will need to apply feedback from
the previous submissions to submit this final portion of the
treatment plan in Week Nine. Please note that Part One and Part
Two of the final project will need to
be submitted in Week Nine to inform the treatment, but they
will not be regraded.
In this assignment, you will demonstrate your mastery of the
following course outcomes:
-610-03: Formulate developmentally appropriate,
culturally sensitive goals, objectives, and interventions to
inform treatment planning
-610-04: Evaluate the use of evidence-based
intervention strategies to inform treatment planning
-610-05: Create a comprehensive, client-centered,
culturally relevant treatment plan to complete a comprehensive
case conceptualization
-610-06: Assess current trends and contemporary issues
across mental health service delivery modalities as they relate
to treatment planning
Prompt
Specifically, you must address the critical elements listed
below. Most of the critical elements align with a particular
course outcome (shown in brackets).
I. Treatment Goals [MHC-610-03]
A. Develop a long-term expected outcome of treatment.

II. Treatment Objectives [MHC-610-03]
A. Develop a short-term expected outcome of treatment.
III. Treatment: Theoretical Themes [MHC-610-06]
A. Describe central therapeutic emphasis, providing
directionality to treatment that is keyed to the adaptive pattern
for each goal and objective.
IV. Treatment: Theoretical Strategy [MHC-610-06]
A. Develop an action plan and vehicle for achieving a more
adaptive pattern for each goal and objective.
V. Treatment: Evidence-Based Interventions [MHC-610-04]
A. Develop specific change techniques and tactics related to the
treatment strategy for achieving treatment goals and pattern
change for each goal
and objective.
VI. Treatment Prognosis [MHC-610-05]
A. Summarize the likely course, duration, and outcome of the
mental health condition with or without treatment.
VII. Reevaluation of Treatment Plan [MHC-610-05]
A. Identify the importance of assessing the goal you developed
for your client.
2
VIII. SOAP Note [MHC-610-05]
A. Use clinical reasoning to create a clinical note outlining what

might be observed during a counseling session with the case
client which follows
the SOAP format (Subjective, Objective, Assessment, Plan).
Final Project Pathway
Final Project Part One Submission: Assessment
In Week Three, you will submit the assessment portion of the
treatment plan. It should be a complete, polished artifact
containing all the critical elements of the
final product. This submission will be graded with the Final
Project Part One Rubric.
Final Project Part Two Submission: Diagnosis
In Week Four, you will submit the diagnosis portion of the
treatment plan. It should be a complete, polished artifact
containing all the critical elements of the
final product. This submission will be graded with the Final
Project Part Two Rubric.
Final Project Part Three Submission: Treatment Plan
In Week Nine, you will submit your finished treatment plan. It
should be a complete, polished artifact containing all the
critical elements of the final product,
along with the assessment and diagnosis portions completed in
Parts One and Two. Note that the assessment and diagnosis
portions will not be graded in Week
Nine, but they will inform the treatment plan. This submission
will be graded with the Final Project Part Three Rubric.
Final Project Part Four Submission: Reflection
In Week Ten, you will submit your reflection on the treatment
plan. This will be done using the Q&A tool within Bongo. This
submission will be graded with the
Final Project Part Four Rubric.

Final Project Part Three Rubric
Guidelines for Submission: Your treatment plan must be
formatted using the provided Treatment Plan Template and the
client’s case study. All sections of the
treatment plan must be filled in for this final submission.
Critical Elements Exemplary (100%) Proficient (90%) Needs
Improvement (70%) Not Evident (0%) Value
Treatment Goals
[MHC-610-03]
Meets “Proficient” criteria, and
goal is exceptionally clear and
contextualized
Develops a long-term expected
outcome of treatment
Develops a long-term expected
outcome of treatment, but
submission lacks detail or is
unproductive for the client
Does not develop a long-term
expected outcome of
treatment
12
3

Treatment
Objectives
[MHC-610-03]
Meets “Proficient” criteria, and
goal is exceptionally clear and
contextualized
Develops a short-term
expected outcome of
treatment
Develops a short-term
expected outcome of
treatment, but submission lacks
detail or is unproductive for the
client
Does not develop a short-term
expected outcome of
treatment
12
Treatment:
Theoretical Themes
[MHC-610-06]
Meets “Proficient” criteria and
expertly describes the

treatment theoretical themes
Describes the central
therapeutic emphasis providing
directionality to treatment that
is keyed to the adaptive pattern
for each goal and objective
Describes the central
for each goal and objective, but
lacks detail and/or contains
inconsistencies
Does not describe the central
for each goal and objective
12
Treatment:
Theoretical Strategy
[MHC-610-06]
provides keen insight into how
the action plan supports the
goal and objective
Develops an action plan and
vehicle for achieving a more

adaptive pattern for each goal
and objective
Develops an action plan and
vehicle for achieving a more
adaptive pattern for each goal
and objective, but lacks details,
or plan does not support client
Does not develop an action
plan and vehicle for achieving a
more adaptive pattern for each
goal and objective
12
Treatment:
Evidence-Based
Interventions
[MHC-610-04]
provides keen insight into how
the interventions support the
treatment goals
Develops specific change
techniques and tactics related
to the treatment strategy for
achieving treatment goals and
pattern change for each goal
and objective
Develops specific change
techniques and tactics related

to the treatment strategy for
achieving treatment goals and
pattern change for each goal
and objective, but submission
lacks detail or contains
inconsistencies
Does not develop specific
change techniques and tactics
related to the treatment
strategy for achieving
treatment goals and pattern
change for each goal and
objective
12
Treatment Prognosis
[MHC-610-05]
provides keen insight into the
mental health condition
outcome
Summarizes the likely course,
duration, and outcome of
mental health condition with or
without treatment
Summarizes the likely course,
duration, and outcome of
mental health condition with or
without treatment, but lacks
details and/or contains
inconsistencies

Does not summarize the likely
course, duration, and outcome
of mental health condition with
or without treatment
13
Reevaluation of
Treatment Plan
[MHC-610-05]
demonstrates a sophisticated
awareness of the importance of
reevaluation of the treatment
plan
Identifies the importance of
assessing the goal developed
for the client
Identifies the importance of
assessing the goal developed
for the client, but submission is
inaccurate
Does not identify the
importance of assessing the
goal developed for the client
12

4
SOAP Note Meets “Proficient” criteria and
provides keen insight into
session progress and plan in the
SOAP note
Describes session progress and
plan in the SOAP note
Describes session progress and
plan in the SOAP note but lacks
details or contains inaccuracies
Does not describe session
progress and plan in the SOAP
note
10
Articulation of
Response
Submission is free of errors
related to citations, grammar,
spelling, syntax, and
organization and is presented in
a professional and easy-to-read
format
Submission has no major errors
spelling, syntax, or organization

Submission has major errors
that negatively impact
readability and articulation of
main ideas
Submission has critical errors
that prevent understanding of
ideas
5
Total 100%

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