course materials

1. MSN 5600L Adult Wellness Check up Diagnosis Lab
MSN 5600L Adult Wellness Check up Diagnosis LabMSN 5600L Adult Wellness Check up
Diagnosis Lab6:21 C Grading Rubric write ups Student This sheet is to help you understand
what wGrading Rubric write ups Student This sheet is to help you understand what we are
looking for, and what our margin remarks might be about on your of patients. Since at all of
the white-ups that you hand in are uniform, this represents what MUST be included in every
write- up. 1) Identifying Data ( 5pts): The opening list of the note. It contains age, sex, race,
marital status, etc. The patient complaint should be given in quotes. If the patient has more
than one complaint, each complaint should be listed separately (1, 2, etc.) and each
addressed in the subjective and under the appropriate number. 2) Subjective Data
(__30pts.): This is the historical part of the note. It contains the following: a) Symptom
analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it
better or worse, and associate manifestations.(10pts). b) Review of systems of associated
systems, reporting all pertinent positives and negatives (10pts). c) Any PMH, family hx,
social hx, allergies, medications related to the complaint/problem (10pts). If more than one
chief complaint, each should be written u this manner. 3) Objective Data(_25pt.): Vital signs
need to be present. Height and Weight should be included where appropriate. a)
Appropriate systems are examined, listed in the note and consistent with those identified in
2b.(10pts). b) Pertinent positives and negatives must be documented for each relevant
system. c) Any abnormalities must be fully described. Measure and record sizes of things
(likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and
normal/abnormal to describe things. (5pts). 4) Assessment ( 10pts.): Encounter paragraph
and diagnoses should be clearly listed and worded appropriately including ICD10 codes. 5)
Plan (_15pts.): Be sure to include any teaching, health maintenance and counseling along
with the pharmacological and non-pharmacological measures. If you have more than one
diagnosis, it is helpful to have this section divided into separate numbered sections. 6)
Subjective Objective, Assessment and Management and Consistent (10pts.): Does the note
the appropriate differential diagnosis process? Is there evidence that you know what
systems and what symptoms go with which complaints? The assessment/diagnoses should
be consistent with the subjective section and then the assessment and plan. The
management should be consistent with the assessment/ diagnoses identified. 6:22 C which
complaints? The assessment/diagnoses should be consistent with the subjective section and
then the assessment and plan. MSN 5600L Adult Wellness Check up Diagnosis LabORDER
NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERSThe management should be consistent

2. with the assessment/ diagnoses identified. 7) Clarity of the Write-up(5pts.): Is it literate,
organized and complete? Comments: Total Score: Instructor: . . . Guidelines for Focused
SOAP Notes · Label each section of the SOAP note (each body part and system) Do not use
unnecessary words or complete sentences. Use Standard Abbreviations S: SUBJECTIVE
DATA (information the patient/caregiver tells you). Chief Complaint (CC): a statement
describing the patient’s symptoms, problems, condition, diagnosis, physician-
recommended return(s) for this patient visit. The patient’s own words should be in quotes.
History of present illness (HPI): a chronological description of the development of the
patient’s chief complaint from the first symptom or from the previous encounter to the
present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating
Factors, Relieving Factors, Treatment, Severity- OLDCARTS), or an update on health status
since the last patient encounter. Past Medical History (PMH): Update current medications,
allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-
appropriate immunization status. Family History (FH): Update significant medical
information about the patient’s family (parents, siblings, and children). Include specific
diseases related to problems identified in CC, HPI or ROS. Social History(SH): An age-
appropriate review of significant activities that may include information such as marital
status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of
education and sexual history. Review of Systems (ROS). There are 14 systems for review.
List positive findings and pertinent negatives in systems directly related to the systems
identified in the CC and symptoms which have occurred since last visit; (1) constitutional
symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4)
cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal,
(9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine,
(13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the 6:20
E Management | Soap Note 1MSN 5600L Adult Wellness Check up Diagnosis LabADULT
Wellness Check Up Due by 10/02/2021 at 11:59 pm | Soap Note 1 Adult Wellness Check up
Soap Note 1 Adult Wellness Check up Soap Note 1 “ADULT” Wellness check up (10 points)
Follow the MRU Soap Note Rubric as a guide: Use APA format and must include mia
minimum of 2 Scholarly Citations. Soap notes will be uploaded to Moodle and put through
TURN-It-In (anti-Plagiarism program) Turn it in’s Score must be less than 25% or will not
be accepted for credit; it must be your own work and in your own words. You can resubmit,
Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks
will not be accepted or tolerated and will receive a grade of O (zero) with no resubmissions
allowed. Please see College Handbook regarding Academic Misconduct Statement. Must use
the sample templates for your soap note. Keep this template for when you start clinicals.
The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI,
Assessment, and Plan should be of your own work and individualized to your made-up
patient. W MRU Soap Nate Dubric 2021.1 docx + 6:22 VIIVVV 111111VA 14414415vvvvvu.
0: OBJECTIVE DATA (information you observe, assessment findings, lab results). Sufficient
physical exam should be performed to evaluate areas suggested by the history and patient’s
progress since last visit. Document specific abnormal and relevant negative findings.
Abnormal or unexpected findings should be described. You should include only the

3. information which was provided in the case study, do not include additional data. Record
observations for the following systems if applicable to this patient encounter (there are 12
possible systems for examination): Constitutional (e.g. vita! signs, general appearance),
Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological,
Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only
include systems for which you have been given data. NOTE: Cardiovascular and Respiratory
systems should be assessed on every patient regardless of the chief complaint. Testing
Results: Results of any diagnostic or lab testing ordered during that patient visit. A:
ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code) List and
number the possible diagnoses (problems) you have identified. These diagnoses are the
conclusions you have drawn from the subjective and objective data. Remember: Your
subjective and objective data should your diagnoses and your therapeutic plan. Do not
write that a diagnosis is to be “ruled out” rather state the working definitions of each
differential or primary diagnosis (es). For each diagnoses provide a cited rationale for
choosing this diagnosis. MSN 5600L Adult Wellness Check up Diagnosis LabThis rationale
includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the
common signs and symptoms, the patients presenting signs and symptoms and the focused
PE findings and tests results that the dx. Include the interpretation of all lab data given in
the case study and explain how those results your chosen diagnosis. P: PLAN (this is your
treatment plan specific to this patient). Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing information and provide EBP
to ordering each medication. Be sure to include both prescription and OTC medications. 2.
Additional diagnostic tests include EBP citations to ordering additional tests 3. Education
this is part of the chart and should be brief, this is not a patient education sheet and needs to
have a reference. 4. Referrals include citations to a referral 5. Follow up. Patient follow-up
should be specified with time or circumstances of return. You must provide a reference for
your decision on when to follow up.