SOAP Note

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Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.

Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.

Click here to access the codes.

Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.

Format

Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be no longer than 3-4 pages excluding the title and the references and in 12pt font.

Name your document: SU_NSG6001_W2A2_LastName_FirstInitial.doc.

Submit your document to the Submissions Area by the

Nursing Research

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Identify a potential individual who has been living in a culture other than the one of origin for at least 2 years. This individual must be born outside the United States. The individual can be a patient, friend, or colleague, such as a physician, or acquaintance, but cannot be a relative. The individual must be living in your community and must be currently receiving or have previously received healthcare services in your community. The individual’s race, ethnicity, language, religion, and culturally based beliefs about healthcare and illness should be quite different from yours. The individual must speak your language. An interpreter is not permitted for the actual assessment, which occurs in Milestone 3 (Week 6).

Note: This is the same individual for whom you will develop verbal assessment questions in Milestone 2 and whom you will ask those questions in Milestone 3 and then reflect on your learning about the Course Project and the assessment.

Individuals can come from a variety of settings. Recent immigrants, migrant workers, exchange students, international students, long-term care residents, refugees, coworkers, physicians, patients, employees at local ethnic businesses, religious venues, community centers, and individuals who have recently moved to your community are some suggestions. The individual does not need to be a healthcare worker but must have received healthcare services in the country of origin as well as since arriving in the United States. Speak with the individual, and obtain permission to conduct an assessment later in the course.

. Although you are not performing the official assessment until Milestone 3, it will be necessary to obtain some general information about your individual to complete Milestone 1. This information may come from the individual or Internet sources.

Fill in information about the potential individual using the template. You are expected to write clearly and use proper grammar and spelling and eliminate typos.

Example: KC was born in Hwidiem, Ghana, a small village in Africa, where he did not graduate from high school. He is 72 years old. He immigrated to the United States at age 28 and has lived in Grove City near Columbus, Ohio since then. Hwidiem is considered the provincial capital (fill in information about the community or city as you can find). He was married but divorced after a traumatic brain injury. Since then, he has had many part-time jobs and studies his Bible faithfully. Grove City is a town in Ohio (fill in information about the city or community). Currently, he receives healthcare for his hypertension control. I met him 3 years ago at a senior citizens’ center where I volunteer.

Community Assessment And Analysis Presentation

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The RN to BSN program at Grand Canyon University meets the requirements for clinical competencies as defined by the Commission on Collegiate Nursing Education (CCNE) and the American Association of Colleges of Nursing (AACN), using nontraditional experiences for practicing nurses. These experiences come in the form of direct and indirect care experiences in which licensed nursing students engage in learning within the context of their hospital organization, specific care discipline, and local communities.

This assignment consists of both an interview and a PowerPoint (PPT) presentation.

Assessment/Interview

Select a community of interest in your region. Perform a physical assessment of the community.

Perform a direct assessment of a community of interest using the “Functional Health Patterns Community Assessment Guide.”

Interview a community health and public health provider regarding that person’s role and experiences within the community.

Interview Guidelines

Interviews can take place in-person, by phone, or by Skype.

Develop interview questions to gather information about the role of the provider in the community and the health issues faced by the chosen community.

Complete the “Provider Interview Acknowledgement Form” prior to conducting the interview. Submit this document separately in its respective drop box.

Compile key findings from the interview, including the interview questions used, and submit these with the presentation.

PowerPoint Presentation

Create a PowerPoint presentation of 15-20 slides (slide count does not include title and references slide) describing the chosen community interest.

Include the following in your presentation:

Description of community and community boundaries: the people and the geographic, geopolitical, financial, educational level; ethnic and phenomenological features of the community, as well as types of social interactions; common goals and interests; and barriers, and challenges, including any identified social determinates of health.

Summary of community assessment: (a) funding sources and (b) partnerships.

Summary of interview with community health/public health provider.

Identification of an issue that is lacking or an opportunity for health promotion.

A conclusion summarizing your key findings and a discussion of your impressions of the general health of the community.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA format ting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

Case Report: Application Of Theory

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Case Report: Application of Theory Instructions

Tutor MUST have a good command of the English language

Directions must be followed precisely

Please review the attached Rubric

Details:

In this assignment, learners are required to write a case report addressing the personal knowledge and skills gained in this course and potentially solving an identified practice problem.

General Guidelines:

Use the following information to ensure successful completion of the assignment:

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center. This assignment requires that at least two additional scholarly research sources related to this topic, and at least one in-text citation from each source be included. You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

Directions:

Construct a 2,500-3,000-word (approximately 10-12 pages) case report that includes a problem or situation consistent with a DNP area of practice.

Requirements:

Use a minimum of any two theories discussed in the course to develop the case report.

Apply one or more theories to describe understanding of the problem or situation of focus.

Apply one or more theories to the recommended intervention or solution being proposed.

Develop the case report across the entire scenario from the identified clinical or health care problem through proposing an intervention, implementation, and evaluation using an appropriate research instrument.

Describe the evaluation of the selected research instrument in the case report.

Lastly, explain in full the tenets, rationale for selection (empirical evidence), and clear application using the language of the theory within the case report.

In addition, your case report must include the following:

Introduction with a problem statement.

Brief literature review.

Description of the case/situation/conditions explained from a theoretical perspective.

Discussion that includes a detailed explanation of the synthesized literature findings.

Summary of the case.

Proposed solutions to remedy gaps, inefficiencies, or other issues from a theoretical approach.

Identification of a research instrument to evaluate the proposed solution along with a description of how the instrument could be evaluated.

Conclusion.

Research Ethics And Evaluating Quantitative Research

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Write a critical appraisal that demonstrates comprehension of two quantitative research studies. Use the “Research Critique Guidelines – Part II” document to organize your essay. Successful completion of this assignment requires that you provide a rationale, include examples, and reference content from the study in your responses.

Use the practice problem and two quantitative, peer‐reviewed research articles you identified in the Topic 1 assignment to complete this assignment.

In a 1,000–1,250 word essay, summarize two quantitative studies, explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study. Resources must be no more than 5 years old.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite.

Qualitative Research Critique And Ethical Considerations

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Write a critical appraisal that demonstrates comprehension of two qualitative research studies. Use the “Research Critique Guidelines – Part 1” document to organize your essay. Successful completion of this assignment requires that you provide rationale, include examples, and reference content from the studies in your responses.

Use the practice problem and two qualitative, peer-reviewed research article you identified in the Topic 1 assignment to complete this assignment.

In a 1,000–1,250 word essay, summarize two qualitative studies, explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite

Professional Coder Practicum Documentation Presentation (Medical Billing And Coding)

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As part of your internship with South Padre Medical Center, you are working under the supervision of the coding supervisor, Marla Kauffman. The clinic’s CDI Director, George Bowman, wants to better educate the physicians on the importance of accurate and complete medical records. Therefore, George is planning on beginning a series of education sessions every month. He has asked Marla to prepare a presentation on proper documentation.

Marla thinks that helping with this presentation would be a wonderful opportunity for you during your internship so that you can learn how to improve clinical documentation by identifying some key elements that are missing or unclear inpatient documentation. Marla’s plan for the presentation is to present some cases and examples where the coders did not have the information they needed to code. Marla has asked you to assist in preparing for this presentation by identifying any missing or unclear information from four patient records and drafting a PowerPoint presentation on your findings.

Because you are a new coder, Marla also thinks it would be helpful for you to research the importance of proper documentation and ways to ensure documentation is complete and accurate and then include information from your research findings into your PowerPoint presentation.

Home Visit with Sallie Mae Fisher

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Observe the simulated “Home Visit with Sallie Mae Fisher” video on YouTube

(Sally Mae Home Visit by sage Mohan)

Refer to “Sallie Mae Fisher’s Health History and Discharge Orders” for specifics related to the case study used to inform the assignment.

Using “Home Visit with Sallie Mae Fisher” and “Sallie Mae Fisher’s Health History and Discharge Orders,” complete the following components of this assignment:

Essay Portion

After viewing the home visit, write an essay of 500-750-words in which you do the following:

  1. Identify, prioritize, and describe at least four problems.

Improper Medication Management

Inadequate Nutrition affecting Body weight

Safety and fall

Depression and Grieving

  1. Provide substantiating evidence (assessment data) for each problem identified.
  2. Identify and describe at least four medical and/or nursing interventions.
  3. Discuss your rationale for the interventions identified.

Prepare this step of the assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

Scripted Dialogue Portion

Utilizing the information learned from the home visit, health histories, and discharge orders, write a scripted dialogue in which you provide Sallie Mae with education that describes her problems and the interventions identified to improve her condition. Consider Sallie Mae’s physiological, psychosocial, educational, and spiritual needs when developing your dialogue.

Your dialogue should resemble a script. The following is an example of a few sentences from a scripted dialogue:

Nurse: “Good morning, Salle Mae, my name is _ and I will be your nurse today. I understand you are experiencing problems with _.”

APA format is not required for this part of the assignment, but solid academic writing is expected.

Refer to “Home Visit With Sallie Mae Fisher Grading Criteria.”

Entire Assignment You are required to submit this assignment to LopesWrite. Refer to the directions in the Student Success Center.

PICOT

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When you decide to purchase a new car, you first decide what is important to you. If mileage and dependability are the important factors, you will search for data focused more on these factors and less on color options and sound systems.

The same holds true when searching for research evidence to guide your clinical inquiry and professional decisions. Developing a formula for an answerable, researchable question that addresses your need will make the search process much more effective. One such formula is the PICO(T) format.

In this Discussion, you will transform a clinical inquiry into a searchable question in PICO(T) format, so you can search the electronic databases more effectively and efficiently. You will share this PICO(T) question and examine strategies you might use to increase the rigor and effectiveness of a database search on your PICO(T) question.

To Prepare:

Review the materials offering guidance on using databases, performing keyword searches, and developing PICO(T) questions provided in the Resources.

Review the Resources for guidance and develop a PICO(T) question of interest to you for further study.

Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer.

Chapter 2, “Asking Compelling Clinical Questions” (pp. 33–54)

Chapter 3, “Finding Relevant Evidence to Answer Clinical Questions” (pp. 55–92

Davies, K. S. (2011). Formulating the evidence based practice question: A review of the frameworks for LIS professionals. Evidence Based Library and Information Practice, 6(2), 75–80. https://doi.org/10.18438/B8WS5N. Retrieved from https://ejournals.library.ualberta.ca/index.php/EBLIP/article/viewFile/9741/8144

Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010a). Evidence-based practice, step by step: Asking the clinical question: A key step in evidence-based practice. American Journal of Nursing, 110(3), 58–61.

doi:10.1097/01.NAJ.0000368959.11129.79. Retrieved from https://journals.lww.com/ajnonline/Fulltext/2010/03000/Evidence_Based_Practice,_Step_by_Step__Asking_the.28.aspx

Se,_Step_by_Step__Searching.24.aspx

Post your PICO(T) question, the search terms used, and the names of at least two databases used for your PICO(T) question. Then, describe your search results in terms of the number of articles returned on original research and how this changed as you added search terms using your Boolean operators. Finally, explain strategies you might make to increase the rigor and effectiveness of a database search on your PICO(T) question. Be specific and provide examples.

Research Critiques And PICOT Statement

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Prepare this assignment as a 1,500-1,750 word paper using the instructor feedback from the Topic 1, 2, and 3 assignments and the guidelines below.

PICOT Statement

Revise the PICOT statement you wrote in the Topic 1 assignment.

Research Critiques

In the Topic 2 and Topic 3 assignments you completed a qualitative and quantitative research critique. Use the feedback you received from your instructor on these assignments to finalize the critical analysis of the study by making appropriate revisions.

The completed analysis should connect to your identified practice problem of interest that is the basis for your PICOT statement.

Refer to “Research Critique Guidelines.” Questions under each heading should be addressed as a narrative in the structure of a formal paper.

Proposed Evidence-Based Practice Change

Discuss the link between the PICOT statement, the research articles, and the nursing practice problem you identified. Include relevant details and supporting explanation and use that information to propose evidence-based practice changes.

Prepare this assignment according to the APA guidelines found in the APA Style Guide,

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin.