Nursing homework help

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Your QIP Presentation will take place at the end of the course.  This presentation includes the following elements and will highlight your completed project!

1. Create a power point slide that has the elements below. 

  • Time length 2-5 minutes
  • Slide/Vision Board 1 slide

Elements in the Presentation:

  • State how the article related to the QI
  • Include a graphic in the “Vision Board”, which is ONE Powerpoint slide with graphics that include:
    • Short term goal
    • Long term goal
    • What worked and what did not
    • Outcomes: can show the graph as a small graphic
    • List a strength that assisted you in QIP
    • Personal insights, feelings, your “why”
    • A graphic of yourself participating in the project
    • Visually appropriate graphic images should be discussed to provide a big picture and tie the project together. Ensure images are professionally appropriate. Nursing homework help

“The inherent desire to deeply care for others can put nurses at risk of compassion fatigue and burnout, which can also affect patients and organizations.”  From Self-care and YOU: Caring for the Caregiver.  ANA You Series: Skills for Success.

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As you reflect on this statement and your role as a caregiver, determine if you agree or disagree.  Describe personal experiences of secondary burnout in yourself or others and how you noticed that you were experiencing secondary trauma. What did you do to overcome compassion fatigue and/or burnout?

Please submit at least a paragraph (5 sentences) with correct spelling/grammar.

See Rubric for grading.  NOTE;  a zero (0) will be assigned for any of the four criteria where none of the criteria were met. Nursing homework help

Rubric

Free form comments Reflection Journal Rubric RNBS 4309

Free form comments Reflection Journal Rubric RNBS 4309

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeContent, Feelings, and Thoughts

All or almost all of the entry has a connection to the question prompt. Personal reflection of feelings and thoughts are revealed in the entry.

90 pts

This criterion is linked to a Learning OutcomeMechanics

All or almost all of the entries have correct spelling and grammar. 5 sentences minimum included. Timely submission.

10 pts

Total Points: 100

Respond to the Post that is bellow using one or more of the following approaches: Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectiv

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Respond to the Post that is bellow using one or more of the following approaches: 

Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.

Validate an idea with your own experience and additional sources.

Make a suggestion based on additional evidence drawn from readings, or after synthesizing multiple postings.

NOTE: THE ANSWER THAT YOU ARE GOING TO DO IN REFERENCE OF THIS POST, HAS TO BE IN A POSITIVE WAY, REFLECTING THE POSITIVE OF THE POST THAT THE STUDENT MADE. 

                                           Initial Discussion Post

                                             Literature Searches

          Nursing is a field filled with numerous  policies and procedures.  To understand these policies and procedures,  the practice of research and knowledge acquisition is essential.  The  method of incorporating proper research into daily practice is called  evidence-based practice (Polit & Beck, 2017).  The goal of using  evidence-based practice is to move away from traditions and ritual by  incorporating tested research evidence that supports clinical practices  (Polit & Beck, 2017).

Summary of Article Search

            Based on the  evidence hierarchy by Polit & Beck (2017), and the levels of  evidence presented in class I was able to evaluate research articles  (Walden University, 2018).  When looking for specific research for my  topic, I searched for the highest level of evidence.  There are three  types of research which are: primary, synthesized or secondary, and  others such as expert opinions or practice questions (Polit & Beck,  2017). 

            My PICOT  question is: In patients with acute pain in the emergency department,  what is the effect of Ketamine use for the reduction of pain compared to  opioid medications during their ED visit? To begin the search, I used  the keywords Ketamine, analgesia, sedation and emergency medicine.   Using these words, I was able to find 408 results.  I further limited my  search to ten years which yielded 297 results.  Finally, I used  systematic reviews, meta-analysis and randomized control trials (RCTs)  for my final search narrowing the articles to 111.  Upon examination of  the articles, I found the articles based on systematic reviews,  meta-analysis and RCTs provided detailed research including abstracts,  methods of trials, results, discussion, limitations, and conclusion.   Each of these sections specifies the purpose of the study in detail. 

          Using this framework for literature review  ensures relevant research is used to answer evidence seeking questions.   Davies (2011) comments, “detailed knowledge of the frameworks enables  the searcher to refine strategies to suit each particular situation  rather than trying to fit a search situation to a framework” (p. 79).   By using a timeframe such as the past ten years, it is easier to see the  relevance of the information to clinical practice today.  An active  literature search will yield the most appropriate information for the  question being posed.

References

Davies, K. S. (2011). Formulating the evidence-based practice question: a review of the frameworks. Evidence Based Library and Information Practice, 6(2), 75-80. Retrieved from https://ejournals.library.ualberta.ca/index.php/EBLIP/article/viewFile/97418144

Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Wolters Kluwer.

Walden University Library. (2018). Levels of evidence. Retrieved from http://academicguides.waldenu.edu/c.php?g=80240&p=52322

In this Discussion, you will consider the role you might play in systems development and the ramifications of not being an active participant in systems development.

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n the media introduction to this module, it was suggested that you as a nurse have an important role in the Systems Development Life Cycle (SDLC). With a focus on patient care and outcomes, nurses may

n the media introduction to this module, it was suggested that you as a nurse have an important role in the Systems Development Life Cycle (SDLC). With a focus on patient care and outcomes, nurses may not always see themselves as contributors to the development of new systems. However, as you may have observed in your own experience, exclusion of nurse contributions when implementing systems can have dire consequences.

In this Discussion, you will consider the role you might play in systems development and the ramifications of not being an active participant in systems development.

To Prepare:

  • Review the steps of the Systems Development Life Cycle (SDLC) as presented in the Resources. 
  • Reflect on your own healthcare organization and consider any steps your healthcare organization goes through when purchasing and implementing a new health information technology system.
  • Consider what a nurse might contribute to decisions made at each stage of the SDLC when planning for new health information technology.

Post a description of what you believe to be the consequences of a healthcare organization not involving nurses in each stage of the SDLC when purchasing and implementing a new health information technology system. Provide specific examples of potential issues at each stage of the SDLC and explain how the inclusion of nurses may help address these issues. Then, explain whether you had any input in the selection and planning of new health information technology systems in your nursing practice or healthcare organization and explain potential impacts of being included or not in the decision-making process. Be specific and provide examples.

References:

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

  • Chapter 9, “Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making” (pp. 175–187)
  • Chapter 12, “Electronic Security” (pp. 229–242)
  • Chapter 13, “Workflow and Beyond Meaningful Use” (pp. 245–261)
  • https://www.youtube.com/watch?v=xtpyjPrpyX8https://healthit.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit

Rurbic:

     Excellent   Good   Fair   Poor       Main Posting          Points Range:     45 (45%) – 50 (50%)   Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.  

Supported by at least three current, credible sources. 

Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style

Polypharmacy Interview and Client Teaching Plan

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Polypharmacy Interview and Client Teaching Plan

PATIENT INTERVIEW

NUR2407LL Section RJXB3A2Z Pharmacology Clinical (11 Weeks) – Clinical-Practicum Externship –Internship

 

PATIENT NAME- J M

 

INTERVIWEW

  1. What medications are you taking?

 

I am taking about 10 medications, but right now the medications im taking is 8 medications

 

  1. Before the interview research each of the medications. In your paper include the reason for each medication, the drug classification, the route of administration, the dose, and possible side effects/adverse reactions.

MEDICATIONS-

Medications

 

 Drug class Drug

Route

 Drug

Dose

 Side effects/ Adverse effect
Cefadroxil

 

 Cephalosporins PO 500mg

 

 Diarrhea, Stomach upset or pain.
 Amoldipine Calcium channel blocker PO 5mg Hypotension, bradycardia, weakness.
Apixalan

 

 Anticoagulant/cardiovascular

Factor/ Xa inhibitors

 

 PO 5mg

 

 Fainting, swelling or joint paining
Finasteride

 

 5-al-pha reductase inhibitors PO 5mg

 

 Dry mouth, constipation, constipation.
Losartan

 

 Angiotensin II receptors Antagonists. PO 100mg

 

 Blurred vision, difficulty breathing.
Metformin

 

 Biguanides PO 5mg

 

 Heartburn, weight loss, flatulence.
Tamsulosin

 

 Alpha-1 Blocker PO 0.4m

 

 Headaches, runny nose, infection
Cialis

 

 Phosphodiesterase-5 Enzyme Inhibitors PO 5mg

 

 Muscles pain, indigestion.
Metoprolol

 

 

 Beta block PO 50mg

 

 Dizziness or lightheadedness, depression
Potassium chloride ER

 

 Electrolytes PO 20 MEQ Tablets appears in stool, gas.

 

For the following questions, paraphrase the client’s answers for your written paper.

 

  1. How long have you taken each these medications?

 

According to Jerry, he said he has been taking the above medications for over twenty years (20years.)

 

  1. Do you know why you are taking these medications?

 

His been taking the medication for his high blood pressure, and for prostate due to enlargement and frequent urge to urinate, and lastly for diabetes.

 

  1. Who told you about the medications and why you need to take them? Were you able to ask any questions about the medications and if so were they answered so you understood what was said?

 

His doctor prescribed those medications. And after talking to him about the medications, he was able to tell me about all his medications, the reason for taken them and had no questions regarding them because of it was as a result of what was going on with him medically.

 

  1. How do you feel about taking these medications?

 

He said he felt good about it, because the medicines are treating the medical issues good.

 

  1. Are you taking other medication purchased “over the counter” such as in a drug store? If so, what is it and why are you taking it.

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He said he wasn’t taken any other medication over the counter.

 

  1. How and when do you take your medications?

 

He explained to me vastly that some of his medication was given to him by his home health nurse after he came back from the hospital. But before, he took them himself. Polypharmacy Interview and Client Teaching Plan

 

  1. Do you have any difficulty taking the medications? If so, what happens and how do you deal with any difficulties.

 

He said no that he didn’t have any difficulty taking his medications.

 

  1. Have you ever felt any uncomfortable feelings and/or body reactions to taking these medications? If so, what were they and how were they handled?

 

He explained to me that he had was feeling lightheaded when he started his blood pressure medication amlodipine. But It was handled by his primary care physician.

 

  1. If you had the above reaction, did they take you off the medication and/or replace it with another medication? Were you told why this happened?

 

No he said, but he told his primary care physician who had his medication frequency reduced. And the, lightheadedness stopped. The physician explained to him that it was because of the long-term use and also, blood pressure medication has a side effect of dizziness/ lightheadedness.

 

 

  1. Do you have any reason not to take the medications?

 

He said calmly, that he has no reason not to take it.

 

  1. Have you ever not taken the medication? If so, what was the reason?

 

He said No, because psychological he feels like if he doesn’t take it so bad might happened to him.

 

Ask a final question about whether the client would like to tell you anything further about their medications.

Write a paper describing your research and findings about the medications being taken and the results of the interview. Report your findings in a 3-5-page written paper. In your paper include the reason for each medication, the drug classification, the route of administration, the dose, and possible side effects/adverse reactions. Polypharmacy Interview and Client Teaching Plan

Use accurate and appropriate spelling and grammar and APA Editorial Format for sources used in your written paper.

Develop a teaching plan for this client based on your findings. Based on the findings from the interview, develop a 2-3-page teaching plan to include the following:

 

  1. List one goal for this teaching plan
  2. Describe two to three teaching resources that might be used
  3. Identify two teaching strategies that can be used based on the client interviewed
  4. List specific client instructions regarding the medications and what adverse reactions they should be aware of/and what to do
  5. Identify at least one factor that may negatively influence adherence to the medications and how it can be overcome
  6. If, appropriate, describe how the family might be involved in ensuring the client is on a proper and safe medication regime. Polypharmacy Interview and Client Teaching Plan

 

 

 

Your Course Project should be 7–10 pages in length, with 10-point font, and double-spaced. Include a cover page, table of contents, introduction, body of the report, summary/conclusion, and works cited.

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Course Project – managed care contracts issues

The paper should critically analyze the issues related to your topic within the context of the current healthcare environment, and also considering future directions in U.S. medical care. 

It is expected that the final version of your Course Project will be 7–10 pages in length, with 6–8 sources identified. 

  • Your Course Project should be 7–10 pages in length, with 10-point font, and double-spaced. Include a cover page, table of contents, introduction, body of the report, summary/conclusion, and works cited.
  • Even though this is not a scientific writing assignment, and is mostly creative in nature, references are still very important. At least six authoritative outside references are required. These should be listed on the last page, titled Works Cited.
  • Appropriate citations are required.
  • All DeVry University policies are in effect, including the plagiarism policy.
  • Papers are due during Week 7 of this course.
  • Any questions about this paper may be discussed in the weekly Q & A Discussion topic.
  • This Course Project is worth 320 total points and will be graded on quality of research topic, quality of paper information, use of citations, grammar, and sentence structure.

Then, write a 3-5 page paper on the energy modality selected. Papers should be written in proper APA format including: Title Page, 12pt. font, New Times Roman, 1 inch margins, double spaced, and include a Reference Page.

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massage

Final Project: Energy Modality Paper

Due: Week 8Points: 100

First, select one of the following with your instructor’s approval:

  • Healing Touch

Then, write a 3-5 page paper on the energy modality selected. Papers should be written in proper APA format including: Title Page, 12pt. font, New Times Roman, 1 inch margins, double spaced, and include a Reference Page.

The paper should address the following:

  • Clearly describe the energy modality. Describe all components of the selection. Include any history and acceptance of the practice. 
  • Discuss the effects that the modality will have on the client.
  • Address the indications and contraindications for the given modality.
  • Consider and explain any license considerations needed to practice in Michigan. Include if there are already therapists practicing this modality in the area. Are CEU’s needed to maintain the practice of the modality? 

1) What are the lessons you learned article that you could utilize in your own career?

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Journal Assignment Week 10

Journal Assignment Week 10

Practicum Weekly Resources

Find a peer reviewed journal article in the Walden University Library published in the last 5 years related to one of the following: (see attached pdf file) and citation highlighted in yellow below:

  • Skills needed for employment in informatics
  • Barriers to EHR employment
  • Nursing and technology

Fenton, S. H., Gongora-Ferraez, M. J., & Joost, E. (2012). Health information technology knowledge and skills needed by HIT employers. Applied Clinical Informatics, 3(4), 448-461. doi:10.4338/ACI-2012-09-RA-0035

Journal Assignment—Part 1

In a minimum of 550 words, answer the questions below in APA format and apply the required references as noted below.

After reviewing the Practicum Weekly Resources, record responses to the following in your Journal:

1)       What are the lessons you learned article that you could utilize in your own career?

2)       What specific actions can you take now to prepare to be marketable in the nursing informatics field in the future?

Journal Assignment—Part 2

Note: Each week, you are responsible for locating a scholarly journal article in the Walden Library related to your area(s) of interest. Include in your Journal the reference in proper APA format and provide a brief summary of the article. (See attached pdf file)

Alles, C., Seyfert, K., & Gonzalez, A. (2014). Improving Nurse to Patient Communication on Antepartum Special Care. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 43(Supp 1), S21. doi:10.1111/1552-6909.12413

Journal Assignment—Part 3

Practicum Onsite Visits

Summarize the key activities of your visits to your Practicum site (as appropriate), including with whom you met, what you did, and what you gained from the experience.

This week, I assisted in a Quality and Safety Council meeting, and a Practice Council meeting. The Quality Safety Council meeting started with moments of excellence which included announcements from the participants. The new B12 council member was also introduced (Mrs. Sawyer, Sade). Topics such as hospital acquired pressure ulcers (HAPU) report and the presentation of a new vacutainer for blood draws were discussed. In the area of Professional Growth Development, the quality data discussed how to disseminate the message to others consistently and focus on getting all nurses to truly understand the data presentations. As far as the Culture agenda, how to address the issue of CLABSI’s (Central lined-associated Blood Stream infection) and CAUTI’s (Catheter-associated Urinary Tract Infections) were discussed. Multiple people attended the meeting, but the key members who presented were Tim T., Jocelyn R., Jeff C., Jesse R., Lisa O., and Sade S., all nurses.

The Practice Council meeting also started with moments of excellence. The agenda items were as followed: “In the News” (Mercy  Magnet Mentor needed; 4 years commitment), Collaborative Practice which included infection prevention, education, pharmacy, laboratory, and technology report in which my preceptor discussed the upcoming new G-Tube assessment in Meditech, texting through responder 5 to PCD phones with canned and free text in the works; some part of Maternal Child Health have received a Health Stream 3-module introduction to the process of logging into the upcoming Epic system. Presenters were: April S., Lisa A., Susan H., Andrea L., Kim D., and Maria H.

What nursing interventions are appropriate for Mrs. J. at the time of her admission? Drug therapy is started for Mrs. J. to control her symptoms. What is the rationale for the administration of each of the following medications?

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p1

Hello i need a Good and Positive Comment related with this argument .A paragraph  with no more  100 words.

Amed Napoles Garcia 

1 posts

Re:Topic 3 Mandatory Discussion Question

What nursing interventions are appropriate for Mrs. J. at the time of her admission? Drug therapy is started for Mrs. J. to control her symptoms. What is the rationale for the administration of each of the following medications?

The patient has many complications. The ABC rule is recommended, and, therefore, it is important to control respiratory problem first. The symptoms are indicative of a patient suffering acute heart failure. She needs immediate hospitalization and monitoring. Telemetry monitoring is necessary for 24-48 hours. Additionally, there is need for diuretics, vasodilators, and inotropic support to perfuse the patient (Joseph et al., 2009). Important vital that should be taken and monitored closely include weight, serum creatinine levels, fluid balance, electrolyte levels, and signs of congestion. Tests of BNP, D-dimer, CBC, and liver function are also important (Joseph et al., 2009).

  • IV furosemide (Lasix) cause prompt diuretic effect which results in a decrease in ventricular filling pressures. It improves symptoms in patients suffering ADHF.
  • Enalapril (Vasotec) inhibits angiotensin converting enzyme to widen blood vessels and reduce water quantity in the blood, and, therefore, reduced blood pressure (Goons, McGraw, & Murali, 2011).
  • Metoprolol (Lopressor) is a beta1-blocker and helps in the management of hypertension, heart failure, and angina pectoris.
  • IV morphine sulphate (Morphine) is effective in reducing preload, heart rate, and afterload, and eventually reducing the myocardial oxygen demand (Goons, McGraw, & Murali, 2011).

Describe four cardiovascular conditions that may lead to heart failure and what can be done in the form of medical/nursing interventions to prevent the development of heart failure in each condition.

Four possible cardiovascular conditions that may lead to heart failure include coronary heart disease, hypertension, myocarditis, and arrhythmias (Anderson, 2016). Coronary heart disease is managed through lifestyle changes, medication, and surgery, in certain cases. Hypertension is manageable through medication, lifestyle changes, healthy diets, reducing alcohol, and quitting smoking (Anderson, 2016). Myocarditis is managed through medication, proper rest, and low salt diets. Finally, arrhythmia is managed through medication, pulse monitoring, and managing the risk factors (Anderson, 2016).

Taking into consideration the fact that most mature adults take at least six prescription medications, discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide rationale for each of the interventions you recommend.

Nurses prevent problems resulting from multiple drug interactions by creating an accurate list of all medications of the patients. The list outlines the generic drugs, brand names, doses, time for dosages, and rationale for taking each drug. The list improves accuracy of taking drugs and helps patients take the right drug at the right time. The second intervention involves warning patients against sharing drugs. Third, nurses should warn patients against using old prescriptions/medications. Lastly, nurses should educate patients on how to take medications correctly, according to instructions.

§ Identify one or more issues, related to your role on the committee

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Perform the following tasks:· Complete the reading assignment and the interactive lesson before attempting this assignment.· To complete this assignment:o Review the case study and select one of the

Perform the following tasks:

· Complete the reading assignment and the interactive lesson before attempting this assignment.

· To complete this assignment:

o Review the case study and select one of the committee roles.

o Download the provided PowerPoint template to create a presentation that includes:

§ Your selection as a member on the committee 

§ Identification one or more issues, related to your role on the committee

§ Identification of probable cause(s) of identified issue(s)

§ Proposed recommendations to resolve the identified issues 

§ Reference slide – list of academic references, using APA style 

Ø Case Study

Read the following case study

A good friend of yours is director of nursing at a 220-bed community hospital. Last year the hospital merged with a much larger medical center. One of the upsides, as well as one of the challenges, resulting from this change has been the rapid introduction of new computer systems. The goal is to bring the hospital “up to speed” within 3 years. At present, the Computerized Physician Order Entry (CPOE) is being implemented. The general medical and surgical units went live last month. The ICU, pediatrics, and obstetrics units are scheduled to go live next month. The plan is to work out any kinks or problems on the general units and then go live in the specialty units. Most of the physicians, nurse practitioners, and physician assistants initially complained but are now becoming more comfortable with the computers and are beginning to integrate the CPOE process into their daily routines. Several physicians are now requesting the ability to enter orders from their offices and others are looking into this option. However, three physicians have not commented during this process but are clearly resisting. For example, after performing rounds and returning to their offices they called the unit with verbal orders. After being counseled on this behavior, they began to write the orders on scraps of paper and put these in the patient’s charts or leave them at the nurses’ station. When they were informed that these were not “legal orders,” they began smuggling in order sheets from the non-activated units. In addition, they have been coercing the staff nurses on the units to enter the orders for them. This has taken two forms. Sometimes they sign in and then ask the nurses to enter the orders. Other times they ask the nurses to put the orders in verbally and then they confirm the orders. The nurses feel caught between the hospital’s goals and the need to maintain a good working relationship with these physicians. 

You suggest to your friend (director of nursing) to create an informal committee to review the issues surrounding the CPOE implementation. The committee would determine methods to address these issues, prior to implementing CPOE within the ICU, pediatrics, and obstetrics units. Your friend appreciates the suggestion and forms a small committee with the following members:

· Taylor Terrific, RN – a nurse practitioner

· Dr. Dudley Do-Right – a physician who uses the CPOE system routinely and correctly

· Dr. Frank Burns – a physician who rarely, if ever, uses the CPOE system

The director of nursing asks each committee member to create a short PowerPoint presentation for the committee. The presentation would identify issues that occurred during CPOE implementation, identify potential causes of such issues, and list specific recommendations, based on strong rationale and research, to resolve the identified issues prior to the next CPOE implementation. Each committee member will have a unique perspective, based on their position (i.e., nurse, physician).

Focused SOAP Note On Psychiatric Patient: DEPRESSION

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Focused SOAP Note On Psychiatric Patient: DEPRESSION

1-Select a psychiatric patient of any age ( an Adult): DEPRESSION

2- Create a Focused SOAP Note on this psychiatric patient using the template and exemplar provided

3- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide.  It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required.  After reviewing full details of the rubric, you can use it as a guide. Focused SOAP Note On Psychiatric Patient: DEPRESSION

In the Subjective section, provide:

  • Chief complaint
  • History of present illness (HPI)
  • Past psychiatric history
  • Medication trials and current medications
  • Psychotherapy or previous psychiatric diagnosis
  • Pertinent substance use, family psychiatric/substance use, social, and medical history
  • Allergies
  • ROS

Read rating descriptions to see the grading standards! 

In the Objective section, provide:

  • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
  • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.

Read rating descriptions to see the grading standards!

In the Assessment section, provide:

  • Results of the mental status examination, presented in paragraph form.
  • At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Read rating descriptions to see the grading standards! Focused SOAP Note On Psychiatric Patient: DEPRESSION

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Focused SOAP Note On Psychiatric Patient: DEPRESSION

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

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. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

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Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression.  You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression.  You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently? Focused SOAP Note On Psychiatric Patient: DEPRESSION

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

 

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

 

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

 

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

 

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

 

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

 

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

 

Follow up with PCP as needed and/or for:

 

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

 

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

 

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. Focused SOAP Note On Psychiatric Patient: DEPRESSION