SOAP note asthma with increased wheezing.docx
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A 22-year-old female presents with a three day history of increased wheezing and shortness of breath. She has a history of asthma and works at the local zoo. A SOAP note is created, documenting the patient's history, physical exam findings of wheezing, and diagnosis of asthma exacerbation. Treatment includes an albuterol inhaler and follow up in one week to monitor symptoms.
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13Force-Field AnalysisEmmanuel BoydonUnivers
1
3
Force-Field Analysis
Emmanuel Boydon
University of Arizona Global Campus
BUS 661: Leading Organizational Change
Dr. Paul Frankenhauser
July 26, 2021
Force-Field Analysis
Describe the concept of force-field analysis and the forces that either drive or restrain the change process. Using the force-field analysis model, discuss a change initiative that you are familiar with, and define the key driving forces and key restraining forces that impact the change.
Your paper should be three to four pages in length (excluding the title and reference pages). Your paper must be formatted according to APA style as outlined in the Writing Center, and it must include in-text citations and references for at least two scholarly sources from the University of Arizona Global Campus Library, in addition to the course text
References
Palmer, I., Dunford, R., & Buchanan, D. (2022). Managing organizational change: A multiple perspectives approach (4th ed.). McGraw-Hill Education.
Episodic/Focused SOAP 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 - for instance "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 ie angioedema, anaphylaxis, etc. 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 (previous and current use), any other pertinent data. Always add some health promo question here - such as 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 possib ...
13Force-Field AnalysisEmmanuel BoydonUnivers
1
3
Force-Field Analysis
Emmanuel Boydon
University of Arizona Global Campus
BUS 661: Leading Organizational Change
Dr. Paul Frankenhauser
July 26, 2021
Force-Field Analysis
Describe the concept of force-field analysis and the forces that either drive or restrain the change process. Using the force-field analysis model, discuss a change initiative that you are familiar with, and define the key driving forces and key restraining forces that impact the change.
Your paper should be three to four pages in length (excluding the title and reference pages). Your paper must be formatted according to APA style as outlined in the Writing Center, and it must include in-text citations and references for at least two scholarly sources from the University of Arizona Global Campus Library, in addition to the course text
References
Palmer, I., Dunford, R., & Buchanan, D. (2022). Managing organizational change: A multiple perspectives approach (4th ed.). McGraw-Hill Education.
Episodic/Focused SOAP 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 - for instance "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 ie angioedema, anaphylaxis, etc. 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 (previous and current use), any other pertinent data. Always add some health promo question here - such as 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 possib ...
SOAP NOTE TEMPLATEPlease role play with a volunteer family mem.docx
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source). Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice The term “Rule Out…” cannot be used as a diagnosis. Please describe appearance of area assessed and refrain from using the term “normal” when documenting this note. Please note that requirements for SOAP notes may differ across NP courses.
I. Subjective Data
A. Chief Complain (CC):
B. History of Present Illness (HPI):
C. Last Menstrual Period (LMP- if applicable)
D. Allergies:
E. Past Medical History:
F. Family History:
G. Surgery History:
H. Social History (alcohol, drug or tobacco use):
I. Health Maintenance: ( include last PAP/MAM, immunizations, colonoscopy, PSA, last eye & physical exam, etc.)
J. Lifestyle Patterns (include spiritual beliefs, behaviors, and traditional practices)
K. Current medications:
L. Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
II. Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess additional pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
A. Assessment
Differential Diagnosis (include rationales and cite source)
1.
2.
3.
Medical Diagnosis (include ICD 10 codes)
1.
B: PLAN
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Cultural & Life span considerations
6. Referrals
Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
Please include CPT Code (level of visit)
References: Please include at least 3 evidence-based sources in APA format.
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will
focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will
include evidence
-
based practice guidelines in the management plan,
and include rationales for
differential diagnoses (cite .
Pneumonia Soap Note Acute Conditions Paper.pdf
The patient presents with complaints of shortness of breath, fatigue, fever and a dry cough that has worsened over the past week. On examination, he has decreased breath sounds and crackles on the right side of his chest. He is diagnosed with pneumonia based on his symptoms and physical findings. The treatment plan includes antibiotics, rest, hydration and follow up in one week.
Assignment 1 Lab Assignment Assessing the Abdomen Please note th.docx
Assignment 1: Lab Assignment: Assessing the Abdomen
Please note this assignment is due week 6. Please refer to your resource list as well as your grading rubrics and study guide for week 6. In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. Please use your Resource list and grading rubric as a guide. Please reach out to me if you have any questions regarding this assignment
ABDOMINAL ASSESSMENT
Subjective:
CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
Diagnostics: None
Assessment:
Left lower quadrant pain
Gastroenteritis
PLAN:
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
With regard to the Episodic note case study provided:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify
at least five
possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
What diagnostic tests would be appropriate for this case, and how would the results.
Course Number and NameCourse NURS 210L-ABNURSING CARE PLAN .docx
This document appears to be a rubric for evaluating nursing care plans. It provides criteria for assessing students' care plans across multiple components, including history of present illness, physical assessment, diagnostic tests, past medical history, developmental stages, socioeconomic and psychosocial assessment, potential health deviations, priority nursing diagnoses, planning goals and evaluation, implementation rationale, medications, organization, and overall score. Components are scored on a scale of 4 (exceeds expectations) to 0 (does not meet expectations). The rubric also provides space for instructor comments and signature.
Select one patient (neighbor, family, or friend) and write-up their .docx
Select one patient (neighbor, family, or friend) and write-up their comprehensive health history. Include the following variables: 1.Identifying data. 2.Past medical history. 3.Health status, perceived barriers, and support. 4.Chief complaint (CC). 5.History of present illness (HPI). 6.Family and/or social history (PFSH). 7.Focused review of systems (ROS). 8.Identify age, spiritual values, and cultural variables that were considered and how these variables influenced your interviews or health history. In a 1,000-1,250-word essay, summarize effective interview techniques for collecting a patient's health history. Include the following: 1.Address how to elicit the patient's interpretation of their health status, their perceived barriers, and support. 2.Critique the effectiveness of several history taking techniques with rationale from the readings. Prepare this assignment according to the guidelines found in the APA Style Guide. An abstract is required. I WANT AT LEAST 4 REFERENCES AND CITATIONS
.
For this weeks discussion, we will be looking at local or nationa
For this week's discussion, we will be looking at local or national response protocols that were initiated during a critical incident, and you will choose your topic!
Search reputable local and national media for a man-made disaster to discuss.
Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks.
In your initial post, describe the incident and address the following:
· Determine the incident type and explain your reasoning.
· What resources were deployed for this incident?
· What protocols were implemented successfully, and which were unsuccessful?
· Discuss way to improve the response to this type of incident in the future.
Support your answer with evidence. Please provide a working link to your story source.
NUR 634 SOAP Note Guide and Template
Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type ...
Recommended
13Force-Field AnalysisEmmanuel BoydonUnivers
1
3
Force-Field Analysis
Emmanuel Boydon
University of Arizona Global Campus
BUS 661: Leading Organizational Change
Dr. Paul Frankenhauser
July 26, 2021
Force-Field Analysis
Describe the concept of force-field analysis and the forces that either drive or restrain the change process. Using the force-field analysis model, discuss a change initiative that you are familiar with, and define the key driving forces and key restraining forces that impact the change.
Your paper should be three to four pages in length (excluding the title and reference pages). Your paper must be formatted according to APA style as outlined in the Writing Center, and it must include in-text citations and references for at least two scholarly sources from the University of Arizona Global Campus Library, in addition to the course text
References
Palmer, I., Dunford, R., & Buchanan, D. (2022). Managing organizational change: A multiple perspectives approach (4th ed.). McGraw-Hill Education.
Episodic/Focused SOAP 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 - for instance "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 ie angioedema, anaphylaxis, etc. 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 (previous and current use), any other pertinent data. Always add some health promo question here - such as 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 possib ...
13Force-Field AnalysisEmmanuel BoydonUnivers
1
3
Force-Field Analysis
Emmanuel Boydon
University of Arizona Global Campus
BUS 661: Leading Organizational Change
Dr. Paul Frankenhauser
July 26, 2021
Force-Field Analysis
Describe the concept of force-field analysis and the forces that either drive or restrain the change process. Using the force-field analysis model, discuss a change initiative that you are familiar with, and define the key driving forces and key restraining forces that impact the change.
Your paper should be three to four pages in length (excluding the title and reference pages). Your paper must be formatted according to APA style as outlined in the Writing Center, and it must include in-text citations and references for at least two scholarly sources from the University of Arizona Global Campus Library, in addition to the course text
References
Palmer, I., Dunford, R., & Buchanan, D. (2022). Managing organizational change: A multiple perspectives approach (4th ed.). McGraw-Hill Education.
Episodic/Focused SOAP 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 - for instance "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 ie angioedema, anaphylaxis, etc. 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 (previous and current use), any other pertinent data. Always add some health promo question here - such as 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 possib ...
SOAP NOTE TEMPLATEPlease role play with a volunteer family mem.docx
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source). Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice The term “Rule Out…” cannot be used as a diagnosis. Please describe appearance of area assessed and refrain from using the term “normal” when documenting this note. Please note that requirements for SOAP notes may differ across NP courses.
I. Subjective Data
A. Chief Complain (CC):
B. History of Present Illness (HPI):
C. Last Menstrual Period (LMP- if applicable)
D. Allergies:
E. Past Medical History:
F. Family History:
G. Surgery History:
H. Social History (alcohol, drug or tobacco use):
I. Health Maintenance: ( include last PAP/MAM, immunizations, colonoscopy, PSA, last eye & physical exam, etc.)
J. Lifestyle Patterns (include spiritual beliefs, behaviors, and traditional practices)
K. Current medications:
L. Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
II. Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess additional pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
A. Assessment
Differential Diagnosis (include rationales and cite source)
1.
2.
3.
Medical Diagnosis (include ICD 10 codes)
1.
B: PLAN
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Cultural & Life span considerations
6. Referrals
Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
Please include CPT Code (level of visit)
References: Please include at least 3 evidence-based sources in APA format.
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will
focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will
include evidence
-
based practice guidelines in the management plan,
and include rationales for
differential diagnoses (cite .
Pneumonia Soap Note Acute Conditions Paper.pdf
The patient presents with complaints of shortness of breath, fatigue, fever and a dry cough that has worsened over the past week. On examination, he has decreased breath sounds and crackles on the right side of his chest. He is diagnosed with pneumonia based on his symptoms and physical findings. The treatment plan includes antibiotics, rest, hydration and follow up in one week.
Assignment 1 Lab Assignment Assessing the Abdomen Please note th.docx
Assignment 1: Lab Assignment: Assessing the Abdomen
Please note this assignment is due week 6. Please refer to your resource list as well as your grading rubrics and study guide for week 6. In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. Please use your Resource list and grading rubric as a guide. Please reach out to me if you have any questions regarding this assignment
ABDOMINAL ASSESSMENT
Subjective:
CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
Diagnostics: None
Assessment:
Left lower quadrant pain
Gastroenteritis
PLAN:
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
With regard to the Episodic note case study provided:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify
at least five
possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
What diagnostic tests would be appropriate for this case, and how would the results.
Course Number and NameCourse NURS 210L-ABNURSING CARE PLAN .docx
This document appears to be a rubric for evaluating nursing care plans. It provides criteria for assessing students' care plans across multiple components, including history of present illness, physical assessment, diagnostic tests, past medical history, developmental stages, socioeconomic and psychosocial assessment, potential health deviations, priority nursing diagnoses, planning goals and evaluation, implementation rationale, medications, organization, and overall score. Components are scored on a scale of 4 (exceeds expectations) to 0 (does not meet expectations). The rubric also provides space for instructor comments and signature.
Select one patient (neighbor, family, or friend) and write-up their .docx
Select one patient (neighbor, family, or friend) and write-up their comprehensive health history. Include the following variables: 1.Identifying data. 2.Past medical history. 3.Health status, perceived barriers, and support. 4.Chief complaint (CC). 5.History of present illness (HPI). 6.Family and/or social history (PFSH). 7.Focused review of systems (ROS). 8.Identify age, spiritual values, and cultural variables that were considered and how these variables influenced your interviews or health history. In a 1,000-1,250-word essay, summarize effective interview techniques for collecting a patient's health history. Include the following: 1.Address how to elicit the patient's interpretation of their health status, their perceived barriers, and support. 2.Critique the effectiveness of several history taking techniques with rationale from the readings. Prepare this assignment according to the guidelines found in the APA Style Guide. An abstract is required. I WANT AT LEAST 4 REFERENCES AND CITATIONS
.
For this weeks discussion, we will be looking at local or nationa
For this week's discussion, we will be looking at local or national response protocols that were initiated during a critical incident, and you will choose your topic!
Search reputable local and national media for a man-made disaster to discuss.
Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks.
In your initial post, describe the incident and address the following:
· Determine the incident type and explain your reasoning.
· What resources were deployed for this incident?
· What protocols were implemented successfully, and which were unsuccessful?
· Discuss way to improve the response to this type of incident in the future.
Support your answer with evidence. Please provide a working link to your story source.
NUR 634 SOAP Note Guide and Template
Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type ...
ASSIGNMENT QUESTION Case Study Assignment Assessing the Head, Ey.docx
ASSIGNMENT QUESTION: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.
Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.
In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
To Prepare
· By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
With regard to the case study you were assigned:
· Review this week's Learning Resources and consider the insights they provide.
· Consider what history would be necessary to collect from the patient.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis?
· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Assignment Question
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient's differential diagnosis and justify why you selected each.
Learning objectives:
· Apply assessment skills to diagnose eye, ears, and throat conditions
· Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat
Focused throat Exam
Li.
SOAP NOTE TEMPLATEPlease include a heart exam and lung exam o.docx
SOAP NOTE TEMPLATE
Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis.
Subjective Data
Chief Complain (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP- if applicable)
Allergies:
Past Medical History:
Family History:
Surgery History:
Social History (alcohol, drug or tobacco use):
Current medications:
Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
Assessment
A: Differential Diagnosis Please rule out all differential diagnosis with subjective and objective data and/or lab-work.
1.
2.
3.
B: Medical Diagnosis Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis.
1.
PLAN
A: Orders
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Referrals
B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
KAPLAN SCHOOL OF NURSING
SOAP NOTE/CASE STUDY GRADING RUBRIC
[100 Points Total]
A. Project Content
80 points possible
0
1-5
6-10
11-15
16-20
Score
Presentation of Case, subjective and
No paper submitted
Needs improvement
Partially addressed case and/or Subjective Data. Only 4-6 components addressed.
Partially addressed Case and/or Subjective Data.
Only 7-9 components addressed.
Clearly and thoroughly presents Case and Subjective Data.
All 10 components addressed
20
Objective Data
No Paper submitted
Omitted 5 or more components of the objective data
Omitted 3-4 components of the objective data
Omitted 1-2 components of the objective data
Clearly and thoroughly presents Objective Data. All of the relevant systems addressed based on the CC and HPI
20
Assessment
No Paper submitted
Failed to address the diagnosis and/or differential diagnosis
Diagnosis incorrect but completed a thorough exam and lab work in order to rule in diagnosis
Diagnosis correct but failed to rule in diagnosis with exams or ...
School of Nursing and Allied HealthMSN Case Write Up Assignmen.docx
School of Nursing and Allied Health
MSN Case Write Up Assignment
The purpose of the Case Write-Up Assignment is for your instructor to "see" what you are doing in clinical and "see" how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.
Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.
Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, add an addendum at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.
If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write an addendum at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum.
You are learning to practice evidence-based practice. Support the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your write up is using a research article.
Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)
Note that you
CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups
All case write ups are to be submitted to the appropriate assignment category by the due date. Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requ.
Lab Ethical Concerns.docx
The document provides instructions for a lab assignment involving analysis of 7 ethical case studies related to patients' healthcare situations. Students are asked to choose one case study, detail the health assessment information needed to diagnose the patient, explain how they would respond as an advanced practice nurse using evidence-based guidelines and ethics, and justify their response with 3 references. The case studies involve issues like mandatory vaccines, end-of-life care, access to medications, minors receiving medical care without full consent, and religious objections to treatment.
APA Title page, running head, page numbers, reference sheet. Use L.docx
APA Title page, running head, page numbers, reference sheet. Use Level 1 and 2 headings to make identifying the components of the paper easier. – 5 points after grade calculated from rubric.
TO be successful in the clinical setting do the following:
You need a APA cover sheet, running head and reference page for anything you turn in (Journal, SOAP note, Time Log).
Do Not change the template.
Do use the template located in the Doc Sharing. This is the explanation of the template…this is not the template.
READ every line of this document please.
You must site 2 journal articles in addition to Epocrates/Medscape and text book failure to do so is -10 points outside of the rubric.
All grades are final. No revisions. Do not ask for revisions of SOAP grades.
Nurse Practitioner SOAP Notes
Purpose: To explain what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise. DO NOT INCLUDE IN NOTE
Subjective data value @ 15 points
SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion
Chief Complaint (CC): One to three words explaining why patient came to clinic value 1 point
History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom: value 7 points hint: OLD CART
Write your paragraph in the order of old cart & chart as well if missing paragraph -3.5 if missing list -3.5
Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments/Therapies
Each of these are valued at 0.5 points (maximum 4 points)
Medications: list each one by name with dosage and frequency
Allergies: include specific reactions to medications, foods, insects, environmental
Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses
Past Surgical History (PSH): Dates, indications and types of operations
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function
Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history etc
Immunizations: Last Tdp, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age)
Family History: Parents, Grandparents, siblings, children
Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you. Delete the system if not addressing. DO NOT put wnl or no complaints be specific. Value 3 points
General: any recent weight changes, weakness, fatigue,.
Diagnostic and Clinical Reasoning Paper Assignment.docx
This document provides guidelines for a diagnostic and clinical reasoning paper assignment. Students are instructed to select a complex patient case from their clinical experience and document it using the SOAP note format. The subjective section should include the patient's chief complaint, history of present illness using the OLDCART approach, past medical history, allergies, medications, social history, and family history. The review of systems ensures all important symptoms are covered, particularly those related to the differential diagnosis. The guidelines aim to expand the scope of clinical documentation and critical thinking around complex patient cases.
Health Diagnostic Reasoning.pdf
Most ear, nose, and throat conditions seen in outpatient settings are minor in nature. However, subtle symptoms can sometimes indicate more serious underlying issues that require prompt medical attention. Nurses must be able to differentiate between benign and potentially life-threatening conditions based on a patient's history and presenting symptoms. This involves considering potential differential diagnoses and ordering appropriate tests and exams to reach an accurate diagnosis. The case study assignment requires students to create a focused patient note for their assigned case that outlines the necessary history to collect, exams and tests to order, and includes a list of potential differential diagnoses with evidence-based justification.
Focused SOAP Note and Patient Case PresentationPsychiatric notes.docx
This document provides instructions for students to complete an assignment involving creating a focused SOAP note and case presentation on a patient they examined during practicum. Students are asked to create a SOAP note using the provided template as a guide. They will then use the SOAP note to develop an 8-minute case presentation covering the patient's chief complaint, history, mental status exam, differential diagnoses, primary diagnosis and its alignment with DSM-5 criteria, treatment plan, and follow-up plan. The treatment plan must address medications, alternative treatments, rationales, referrals, and include discussion of a social determinant of health, health promotion activity, and patient education consideration related to the case.
You have been provided with case study in Week 4 that focused on.docx
You have been provided with case study in
Week 4
that focused on genitourinary .You will analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. The paper should be no more than 3 pages typed excluding title page and references.
Criteria:
SOAP note
Evaluation of priority diagnosis
Facilitators and barriers to disorder management
Assignment 2 Grading Criteria
Maximum Points
Introduction
The submission included a general introduction to the priority diagnosis.
10
Subjective Data
The submission included the patient's interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.
15
Objective Data
The submission included the measurements and observations obtained by the nurse practitioner. It included head to toe physical examination, laboratory and diagnostic testing results.
15
Assessment
The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.
20
Plan of Care
Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.
25
Evaluation of Priority Diagnosis
The plan chose the priority diagnosis for the pt and differentiated the disorder from normal development. Discussed the physical and psychological demands the disorder places on the patient and family and key concepts to discuss with them. Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
25
Facilitators and Barriers
The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers.
20
Conclusion
The submission included what should be taken away from this assignment.
10
APA/Style/Format
The submission was free of grammatical, spelling, or punctuation errors. Citations and references were written in correct APA Style.
Utilized proper format with coversheet, header.
10
Total
150
.
Mrs. G, a 55 year old Hispanic female, presents to the office for he.docx
Mrs. G, a 55 year old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep.
Current medications:
Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin
PMH:
Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to
date.
GYN hx:
G2 P1. 1 SAB, 1 living child, full term, wt 9lbs 2 oz. LMP 15months ago. No history of abnormal Pap smear.
FH:
parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol.
SH:
works from home part time as a planning coordinator. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use
Allergies
: NKDA, allergic to cats and pollen. No latex allergy
Vital signs
: BP 129/80; pulse 76, regular; respiration 16, regular
Height 5’2.5”, weight 185 pounds
General:
obese female in no acute distress. Alert, oriented and cooperative.
Skin
: warm dry and intact. No lesions noted
HEENT:
head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV
: S1 and S2 RRR without murmurs or rubs
Lungs
: Clear to auscultation bilaterally, respirations unlabored.
Abdomen
- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.
Labwork:
CBC
:
WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC
34 g/dl RDW 13.8%
UA:
pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones
CMP:
Sodium 139
Potassium 4.3
Chloride 100
CO2 29
Glucose 95
BUN 12
Creatinine 0.7
GFR est non-AA 92 mL/min/1.73 GFR est AA 101 mL/min/1.73 Calcium 9.5
Total protein 7.6 Bilirubin, total 0.6 Alkaline.
Article Analysis Essay Discussion Paper.docx
This document provides information on three research articles related to healthcare. The first article examines the verbal behavior and emotional tone of patients with tinnitus and hyperacusis. The second article discusses diagnoses, outcomes, and nursing interventions for 152 patients who underwent c-sections. The third article reviews research on the effects of massage therapy and therapeutic touch for children ages 2-16 with various medical conditions. Key details are provided on the research questions, populations, samples, methods, results and conclusions of each study.
Case Studies Assignment Discussion Paper.docx
This document contains subjective and objective data from an annual wellness exam of a 29-year-old female patient.
The subjective data includes the patient's chief complaint of an annual wellness visit with no current issues. Her past medical, social, and family histories are documented.
The objective exam findings are thoroughly documented and include vital signs, general appearance, examinations of various body systems, and normal lab test results.
Competency Evaluate outcomes of.pdf
The document provides instructions for a nursing student to create a concept map and narrative report for a patient case study. The student must design an individualized concept map for a patient with gestational diabetes based on her health, economic, and cultural needs. In a 2-4 page narrative, the student must analyze the patient's needs, justify evidence used, propose outcomes criteria, and develop a culturally sensitive communication plan. The narrative should follow APA style and address all specified sections and competencies.
CNA253255 Clinical reasoning case-study rubric Asses.docx
CNA253/255
Clinical reasoning case-study rubric
Assessment Criteria HD DN CR PP NN
Explains relevant
underlying physiology/
pathophysiology related
to the health status of the
individual and
demonstrates
understanding of the
relationship between the
health issues presented.
40%
Demonstrates a high-
level of application of
knowledge to the case,
that accurately and
comprehensively
explains the students'
understanding of the
underlying
pathophysiological
mechanisms related to
the patient's condition.
Accurate application of
knowledge that indicates
a high-level
understanding of relevant
pathophysiological
mechanisms related to
the patient's condition.
Mostly accurate
application of knowledge
that indicates a
reasonable level of
understanding of relevant
pathophysiological
mechanisms related to
the patient's condition.
Some scope to detail
additional relationships
within the case study.
Demonstrates a
satisfactory application of
mostly accurate
knowledge regarding
some of the relevant
pathophysiological
mechanisms. Scope for
additional depth and
analysis.
Provides insufficient
and/or confused
knowledge that does not
clearly demonstrate an
understanding of relevant
pathophysiological
mechanisms.
Demonstrates ability to
appropriately apply the
clinical reasoning cycle to
inform and evaluate
nursing care
40%
Demonstrates an
exceptional
understanding and
application of all
components of the
clinical reasoning cycle
to the case that
indicates an emerging
capacity to think like a
registered nurse. The
plan of care detailed
provides evidence of
high-level thinking
around relevant course
of actions and impact/s
on future nursing
practice.
Demonstrates a strong
understanding of the
application of most
components of the
clinical reasoning cycle to
the case that indicates an
emerging capacity to
think like a registered
nurse. Details an
appropriate, relevant
course of actions and
impact/s on future
nursing practice.
Demonstrates a clear but
sometimes limited
understanding of the
application of clinical
reasoning with some
capacity to think like a
registered nurse, but
scope for more depth.
Demonstrates a
satisfactory approach to
application of some
elements of the clinical
reasoning with some
capacity to think like a
registered nurse, but
scope for more depth.
Paper is not aligned with
the clinical reasoning
cycle and/or
demonstrates poor
understanding of its
application and does not
clearly address and/or
acknowledge the patient
problem.
Uses appropriate scholarly
literature to substantiate
findings throughout. Uses
Harvard referencing style.
10%
Accurately references all
sources using the
Harvard style.
Outstanding use of
appropriate academic
literature that
substantiates thinking
and arguments that
considers evidence-
based practice rel ...
Social What directed your interest to this.docx
The document discusses why the person is interested in social work. They grew up seeing friends' parents addicted to drugs and in foster care, directing their interest to help address problems like drugs, poverty, and lack of guidance. Their goals are to open a teenage shelter and drug rehab programs one day. They believe their dedication enables them to study and practice social work to help address important social issues.
Soap notes will be uploaded to Moodle and put through.docx
This soap note documents a visit for a 65-year-old male patient complaining of headaches for the past two weeks. On examination, the patient's blood pressure was elevated on multiple readings. The assessment is essential (primary) hypertension. The plan includes starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications and follow up with his primary care provider in one week to evaluate blood pressure control. No referrals are needed at this time.
Social Poverty.docx
Poverty is one of four social issues that students must write a 400-450 word mini-essay about for a class assignment. The assignment requires students to choose three social issues to write about, with the fourth essay topic being on poverty. All four mini-essays must be combined into a single document and meet the 1,200 total word count for the assignment.
Soap Note Diabetes Mellitus.docx
1) This soap note document outlines the typical sections and information included in a soap note for a patient with diabetes mellitus. It includes sections for identifying data, subjective data, objective data, assessment, and plan.
2) The subjective section includes symptoms, review of systems, past medical history, family history, social history, and allergies/medications as they relate to the complaint.
3) The objective section includes vital signs, physical exam findings described in detail for relevant systems, and any abnormalities fully described.
Social Disorganization.docx
Social disorganization refers to the inability of a community to realize common values or solve emerging problems. Socially disorganized neighborhoods typically have high rates of poverty, residential mobility, and ethnic heterogeneity which undermine the ability of a community to exercise informal social control. Research shows that socially disorganized areas tend to have weaker social ties between neighbors and higher crime rates.
SOC101 Assignment Sheet Interview.docx
This document provides instructions for a SOC101 assignment where students are asked to interview someone over age 65 about their experiences with age and happiness. The interview is meant to help students connect course concepts to real life by gaining perspectives from other demographics. Students are given qualitative questions to ask and should write a substantive report summarizing the conversation rather than providing a full transcript, keeping the subject anonymous.
Slide 1 Title Page Slide 2 3.docx
This presentation discusses the diagnosis and treatment of bipolar disorder and major depressive disorder based on a case scenario. It outlines the diagnostic criteria and symptoms of bipolar disorder and major depressive disorder, describing treatment strategies and interventions for each, such as medications and therapies. The presentation concludes with a reference page.
Social media sites have recently drew decision attention and influenced.docx
Employers are increasingly using social media to evaluate potential job candidates, with sites like LinkedIn and Facebook providing profiles and information to aid hiring decisions. However, social media may not always accurately reflect candidates and could include fake or misleading information, making it difficult for employers to properly assess candidates and determine the right fit based on online profiles alone. More research is needed to understand how social media has impacted hiring and how employers can mitigate risks of relying too heavily on digital profiles.
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ASSIGNMENT QUESTION Case Study Assignment Assessing the Head, Ey.docx
ASSIGNMENT QUESTION: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.
Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.
In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
To Prepare
· By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
With regard to the case study you were assigned:
· Review this week's Learning Resources and consider the insights they provide.
· Consider what history would be necessary to collect from the patient.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis?
· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Assignment Question
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient's differential diagnosis and justify why you selected each.
Learning objectives:
· Apply assessment skills to diagnose eye, ears, and throat conditions
· Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat
Focused throat Exam
Li.
SOAP NOTE TEMPLATEPlease include a heart exam and lung exam o.docx
SOAP NOTE TEMPLATE
Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis.
Subjective Data
Chief Complain (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP- if applicable)
Allergies:
Past Medical History:
Family History:
Surgery History:
Social History (alcohol, drug or tobacco use):
Current medications:
Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
Assessment
A: Differential Diagnosis Please rule out all differential diagnosis with subjective and objective data and/or lab-work.
1.
2.
3.
B: Medical Diagnosis Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis.
1.
PLAN
A: Orders
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Referrals
B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
KAPLAN SCHOOL OF NURSING
SOAP NOTE/CASE STUDY GRADING RUBRIC
[100 Points Total]
A. Project Content
80 points possible
0
1-5
6-10
11-15
16-20
Score
Presentation of Case, subjective and
No paper submitted
Needs improvement
Partially addressed case and/or Subjective Data. Only 4-6 components addressed.
Partially addressed Case and/or Subjective Data.
Only 7-9 components addressed.
Clearly and thoroughly presents Case and Subjective Data.
All 10 components addressed
20
Objective Data
No Paper submitted
Omitted 5 or more components of the objective data
Omitted 3-4 components of the objective data
Omitted 1-2 components of the objective data
Clearly and thoroughly presents Objective Data. All of the relevant systems addressed based on the CC and HPI
20
Assessment
No Paper submitted
Failed to address the diagnosis and/or differential diagnosis
Diagnosis incorrect but completed a thorough exam and lab work in order to rule in diagnosis
Diagnosis correct but failed to rule in diagnosis with exams or ...
School of Nursing and Allied HealthMSN Case Write Up Assignmen.docx
School of Nursing and Allied Health
MSN Case Write Up Assignment
The purpose of the Case Write-Up Assignment is for your instructor to "see" what you are doing in clinical and "see" how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.
Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.
Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, add an addendum at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.
If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write an addendum at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum.
You are learning to practice evidence-based practice. Support the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your write up is using a research article.
Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)
Note that you
CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups
All case write ups are to be submitted to the appropriate assignment category by the due date. Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requ.
Lab Ethical Concerns.docx
The document provides instructions for a lab assignment involving analysis of 7 ethical case studies related to patients' healthcare situations. Students are asked to choose one case study, detail the health assessment information needed to diagnose the patient, explain how they would respond as an advanced practice nurse using evidence-based guidelines and ethics, and justify their response with 3 references. The case studies involve issues like mandatory vaccines, end-of-life care, access to medications, minors receiving medical care without full consent, and religious objections to treatment.
APA Title page, running head, page numbers, reference sheet. Use L.docx
APA Title page, running head, page numbers, reference sheet. Use Level 1 and 2 headings to make identifying the components of the paper easier. – 5 points after grade calculated from rubric.
TO be successful in the clinical setting do the following:
You need a APA cover sheet, running head and reference page for anything you turn in (Journal, SOAP note, Time Log).
Do Not change the template.
Do use the template located in the Doc Sharing. This is the explanation of the template…this is not the template.
READ every line of this document please.
You must site 2 journal articles in addition to Epocrates/Medscape and text book failure to do so is -10 points outside of the rubric.
All grades are final. No revisions. Do not ask for revisions of SOAP grades.
Nurse Practitioner SOAP Notes
Purpose: To explain what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise. DO NOT INCLUDE IN NOTE
Subjective data value @ 15 points
SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion
Chief Complaint (CC): One to three words explaining why patient came to clinic value 1 point
History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom: value 7 points hint: OLD CART
Write your paragraph in the order of old cart & chart as well if missing paragraph -3.5 if missing list -3.5
Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments/Therapies
Each of these are valued at 0.5 points (maximum 4 points)
Medications: list each one by name with dosage and frequency
Allergies: include specific reactions to medications, foods, insects, environmental
Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses
Past Surgical History (PSH): Dates, indications and types of operations
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function
Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history etc
Immunizations: Last Tdp, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age)
Family History: Parents, Grandparents, siblings, children
Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you. Delete the system if not addressing. DO NOT put wnl or no complaints be specific. Value 3 points
General: any recent weight changes, weakness, fatigue,.
Diagnostic and Clinical Reasoning Paper Assignment.docx
This document provides guidelines for a diagnostic and clinical reasoning paper assignment. Students are instructed to select a complex patient case from their clinical experience and document it using the SOAP note format. The subjective section should include the patient's chief complaint, history of present illness using the OLDCART approach, past medical history, allergies, medications, social history, and family history. The review of systems ensures all important symptoms are covered, particularly those related to the differential diagnosis. The guidelines aim to expand the scope of clinical documentation and critical thinking around complex patient cases.
Health Diagnostic Reasoning.pdf
Most ear, nose, and throat conditions seen in outpatient settings are minor in nature. However, subtle symptoms can sometimes indicate more serious underlying issues that require prompt medical attention. Nurses must be able to differentiate between benign and potentially life-threatening conditions based on a patient's history and presenting symptoms. This involves considering potential differential diagnoses and ordering appropriate tests and exams to reach an accurate diagnosis. The case study assignment requires students to create a focused patient note for their assigned case that outlines the necessary history to collect, exams and tests to order, and includes a list of potential differential diagnoses with evidence-based justification.
Focused SOAP Note and Patient Case PresentationPsychiatric notes.docx
This document provides instructions for students to complete an assignment involving creating a focused SOAP note and case presentation on a patient they examined during practicum. Students are asked to create a SOAP note using the provided template as a guide. They will then use the SOAP note to develop an 8-minute case presentation covering the patient's chief complaint, history, mental status exam, differential diagnoses, primary diagnosis and its alignment with DSM-5 criteria, treatment plan, and follow-up plan. The treatment plan must address medications, alternative treatments, rationales, referrals, and include discussion of a social determinant of health, health promotion activity, and patient education consideration related to the case.
You have been provided with case study in Week 4 that focused on.docx
You have been provided with case study in
Week 4
that focused on genitourinary .You will analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. The paper should be no more than 3 pages typed excluding title page and references.
Criteria:
SOAP note
Evaluation of priority diagnosis
Facilitators and barriers to disorder management
Assignment 2 Grading Criteria
Maximum Points
Introduction
The submission included a general introduction to the priority diagnosis.
10
Subjective Data
The submission included the patient's interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.
15
Objective Data
The submission included the measurements and observations obtained by the nurse practitioner. It included head to toe physical examination, laboratory and diagnostic testing results.
15
Assessment
The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.
20
Plan of Care
Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.
25
Evaluation of Priority Diagnosis
The plan chose the priority diagnosis for the pt and differentiated the disorder from normal development. Discussed the physical and psychological demands the disorder places on the patient and family and key concepts to discuss with them. Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
25
Facilitators and Barriers
The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers.
20
Conclusion
The submission included what should be taken away from this assignment.
10
APA/Style/Format
The submission was free of grammatical, spelling, or punctuation errors. Citations and references were written in correct APA Style.
Utilized proper format with coversheet, header.
10
Total
150
.
Mrs. G, a 55 year old Hispanic female, presents to the office for he.docx
Mrs. G, a 55 year old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep.
Current medications:
Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin
PMH:
Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to
date.
GYN hx:
G2 P1. 1 SAB, 1 living child, full term, wt 9lbs 2 oz. LMP 15months ago. No history of abnormal Pap smear.
FH:
parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol.
SH:
works from home part time as a planning coordinator. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use
Allergies
: NKDA, allergic to cats and pollen. No latex allergy
Vital signs
: BP 129/80; pulse 76, regular; respiration 16, regular
Height 5’2.5”, weight 185 pounds
General:
obese female in no acute distress. Alert, oriented and cooperative.
Skin
: warm dry and intact. No lesions noted
HEENT:
head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV
: S1 and S2 RRR without murmurs or rubs
Lungs
: Clear to auscultation bilaterally, respirations unlabored.
Abdomen
- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.
Labwork:
CBC
:
WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC
34 g/dl RDW 13.8%
UA:
pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones
CMP:
Sodium 139
Potassium 4.3
Chloride 100
CO2 29
Glucose 95
BUN 12
Creatinine 0.7
GFR est non-AA 92 mL/min/1.73 GFR est AA 101 mL/min/1.73 Calcium 9.5
Total protein 7.6 Bilirubin, total 0.6 Alkaline.
Article Analysis Essay Discussion Paper.docx
This document provides information on three research articles related to healthcare. The first article examines the verbal behavior and emotional tone of patients with tinnitus and hyperacusis. The second article discusses diagnoses, outcomes, and nursing interventions for 152 patients who underwent c-sections. The third article reviews research on the effects of massage therapy and therapeutic touch for children ages 2-16 with various medical conditions. Key details are provided on the research questions, populations, samples, methods, results and conclusions of each study.
Case Studies Assignment Discussion Paper.docx
This document contains subjective and objective data from an annual wellness exam of a 29-year-old female patient.
The subjective data includes the patient's chief complaint of an annual wellness visit with no current issues. Her past medical, social, and family histories are documented.
The objective exam findings are thoroughly documented and include vital signs, general appearance, examinations of various body systems, and normal lab test results.
Competency Evaluate outcomes of.pdf
The document provides instructions for a nursing student to create a concept map and narrative report for a patient case study. The student must design an individualized concept map for a patient with gestational diabetes based on her health, economic, and cultural needs. In a 2-4 page narrative, the student must analyze the patient's needs, justify evidence used, propose outcomes criteria, and develop a culturally sensitive communication plan. The narrative should follow APA style and address all specified sections and competencies.
CNA253255 Clinical reasoning case-study rubric Asses.docx
CNA253/255
Clinical reasoning case-study rubric
Assessment Criteria HD DN CR PP NN
Explains relevant
underlying physiology/
pathophysiology related
to the health status of the
individual and
demonstrates
understanding of the
relationship between the
health issues presented.
40%
Demonstrates a high-
level of application of
knowledge to the case,
that accurately and
comprehensively
explains the students'
understanding of the
underlying
pathophysiological
mechanisms related to
the patient's condition.
Accurate application of
knowledge that indicates
a high-level
understanding of relevant
pathophysiological
mechanisms related to
the patient's condition.
Mostly accurate
application of knowledge
that indicates a
reasonable level of
understanding of relevant
pathophysiological
mechanisms related to
the patient's condition.
Some scope to detail
additional relationships
within the case study.
Demonstrates a
satisfactory application of
mostly accurate
knowledge regarding
some of the relevant
pathophysiological
mechanisms. Scope for
additional depth and
analysis.
Provides insufficient
and/or confused
knowledge that does not
clearly demonstrate an
understanding of relevant
pathophysiological
mechanisms.
Demonstrates ability to
appropriately apply the
clinical reasoning cycle to
inform and evaluate
nursing care
40%
Demonstrates an
exceptional
understanding and
application of all
components of the
clinical reasoning cycle
to the case that
indicates an emerging
capacity to think like a
registered nurse. The
plan of care detailed
provides evidence of
high-level thinking
around relevant course
of actions and impact/s
on future nursing
practice.
Demonstrates a strong
understanding of the
application of most
components of the
clinical reasoning cycle to
the case that indicates an
emerging capacity to
think like a registered
nurse. Details an
appropriate, relevant
course of actions and
impact/s on future
nursing practice.
Demonstrates a clear but
sometimes limited
understanding of the
application of clinical
reasoning with some
capacity to think like a
registered nurse, but
scope for more depth.
Demonstrates a
satisfactory approach to
application of some
elements of the clinical
reasoning with some
capacity to think like a
registered nurse, but
scope for more depth.
Paper is not aligned with
the clinical reasoning
cycle and/or
demonstrates poor
understanding of its
application and does not
clearly address and/or
acknowledge the patient
problem.
Uses appropriate scholarly
literature to substantiate
findings throughout. Uses
Harvard referencing style.
10%
Accurately references all
sources using the
Harvard style.
Outstanding use of
appropriate academic
literature that
substantiates thinking
and arguments that
considers evidence-
based practice rel ...
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