PRAC – 6665 Week 3: Focused SOAP Note and Patient Case Presentation

Introduction

Consider the experiences you have had thus far, either in the healthcare workplace or at your practicum site. As you likely know, a nurse’s job does not begin and end with one-to-one patient contact. It includes meetings, documentation, trainings, and collaboration. In particular, the nurse is a member of an interdisciplinary team and must use oral and written communication to inform others of a patient’s status. A central skill of advanced practice nursing, then, is the ability to present a patient’s history, symptoms, diagnosis, and treatment plan to relevant parties involved in treatment. PRAC – 6665 Week 3: Focused SOAP Note and Patient Case Presentation

This week, in addition to your Meditrek tracking, you will develop a focused SOAP note and video case presentation on one of the patients you have examined in your clinical practicum.

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Learning Objectives

Students will:

• Describe clinical hours and patient encounters
• Assess patients across the lifespan in mental health settings
• Formulate differential diagnoses for patients across the lifespan in mental health settings
• Develop plans of care for patients across the lifespan in mental health settings
• Advocate health promotion and patient education strategies across the lifespan
• Develop a case study presentation based on a clinical patient

Learning Resources

Required Readings (click to expand/reduce)

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

• Section II. The Psychiatric History (Chapters 14–18)
• Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)

Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. In J. M. Rey & A. Martin (Eds.), IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/content/uploads/A.7-Psychopharmacology-2019.1.pdf

Meditrek

https://edu.meditrek.com/Default.html
Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.

Document: Focused SOAP Note Template (Word document)

Document: Focused SOAP Note Exemplar (Word document)

Assignment 1: Clinical Hour and Patient Logs

Photo Credit: auremar / Adobe Stock

Clinical Hour Log
For this course, all practicum activity hours are logged within the Meditrek system. Hours completed must be logged in Meditrek within 48 hours of completion in order to be counted.
You may only log hours with Preceptors that are approved in Meditrek. Students with catalog years before Spring 2018 must complete a minimum of 576 hours of supervised clinical experience (144 hours in each practicum course). Students with catalog years beginning Spring 2018 must complete a minimum of 640 hours of supervised clinical experience (160 hours in each practicum course). PRAC – 6665 Week 3: Focused SOAP Note and Patient Case Presentation

Each log entry must be linked with an individual practicum Learning Objective or a graduate Program Objective. You should track your hours in Meditrek as they are completed.

Your clinical hour log must include the following:

• Dates
• Course
• Clinical Faculty
• Preceptor
• Total Time (for the day)
• Notes/Comments (including the objective to which the log entry is aligned)

Patient Log

Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 encounters with patients by the end of this practicum (40 children/adolescents and 40 adult/older adult).

The patient log must include the following:

• Date
• Course
• Clinical Faculty
• Preceptor
• Patient Number
• Client Information
• Visit Information
• Practice Management
• Diagnosis
• Treatment Plan and Notes: You must include a brief summary/synopsis of the patient visit. This does not need to be a SOAP note, however the note needs to be sufficient to remember your patient encounter.

By Day 7 of Week 3

Record your clinical hours and patient encounters in Meditrek.

Assignment 2: Focused SOAP Note and Patient Case Presentation

Photo Credit: Pexels

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. PRAC – 6665 Week 3: Focused SOAP Note and Patient Case Presentation

To Prepare

• Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
  Please Note: 
  • All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
  • When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
  • You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
• Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentation:

• Dress professionally with a lab coat and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.
  • Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be. PRAC – 6665 Week 3: Focused SOAP Note and Patient Case Presentation
    

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By Day 7 of Week 3

Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “WK3Assgn2+last name+first initial.(extension)” as the name.
• Click the Week 3 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 3 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK3Assgn2+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:

Week 3 Assignment 2 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 3 Assignment 2 draft and review the originality report.

Submit Your Assignment by Day 7 of Week 3

To participate in this Assignment:

Week 3 Assignment 2

PRAC – 6665 Week 3: Focused SOAP Note and Patient Case Presentation

NURS 6501N Week 8: Concepts of Neurological and Musculoskeletal Disorders

Patient is a 24-year-old female administrative assistant who comes to the emergency department with a chief complaint of severe right-sided headache. She states that this is the sixth time in the last 2 months she has had this headache. She says the headaches last 2–3 days and have impacted her ability to concentrate at work. She complains of nausea and has vomited three times in the last 3 hours. She states, “the light hurts my eyes.” She rates her pain as a 10/10 at this time. Ibuprofen and acetaminophen ease her symptoms somewhat but do not totally relieve them. No other current complaints.

Thanks,

NURSFPX 4900 Capella University Nursing Global Health Concerns Essay

INSTRUCTIONS

In a 5-7 page written assessment, define the patient, family, or population health problem that will be the focus of your capstone project. Assess the problem from a leadership, collaboration, communication, change management, and policy perspective. Plan to spend approximately 2 direct practicum hours meeting with a patient, family, or group of your choice to explore the problem and, if desired, consulting with subject matter and industry experts.

Nurses in all professional roles work to effect positive patient outcomes and improve organizational processes. Professional nurses are leaders in problem identification, planning, and strategy implementation—skills that directly affect patient care or organizational effectiveness. NURSFPX 4900 Capella University Nursing Global Health Concerns Essay

Too often, change agents jump to a conclusion that an intervention will promote the envisioned improvement. Instead, the ideal approach is to determine which interventions are appropriate, based on an assessment and review of credible evidence. Interventions could be patient-facing or involve a change in policy and process. In this assessment, you’ll identify and make the case for your practicum focus area, then explore it in depth from a leadership, collaboration, communication, change management, and policy perspective.

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This assessment lays the foundation for the work that will carry you through your capstone experience and guide the practicum hours needed to complete the work in this course. In addition, it will enable you to do the following:

• Develop a problem statement for a patient, family, or population that’s relevant to your practice.
• Begin building a body of evidence that will inform your approach to your practicum.
• Focus on the influence of leadership, collaboration, communication, change management, and policy on the problem.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 1: Lead people and processes to improve patient, systems, and population outcomes.
  • Define a patient, family, or population health problem that’s relevant to personal and professional practice.
• Competency 2: Make clinical and operational decisions based upon the best available evidence.
  • Analyze evidence from peer-reviewed literature and professional sources that describes and guides nursing actions related to a defined patient, family, or population problem.
• Competency 5: Analyze the impact of health policy on quality and cost of care.
  • Explain how state board nursing practice standards and/or organizational or governmental policies could affect a defined patient, family, or population problem. NURSFPX 4900 Capella University Nursing Global Health Concerns Essay
• Competency 7: Implement patient-centered care to improve quality of care and the patient experience.
  • Propose leadership strategies to improve outcomes, patient-centered care, and the patient experience related to a defined patient, family, or population problem.
• Competency 8: Integrate professional standards and values into practice.
  • Organize content so ideas flow logically with smooth transitions.
  • Apply APA style and formatting to scholarly writing.

Preparation

In this assessment, you’ll assess the patient, family, or population health problem that will be the focus of your capstone project. Plan to spend approximately 2 hours working with a patient, family, or group of your choice to explore the problem from a leadership, collaboration, communication, change management, and policy perspective. During this time, you may also choose to consult with subject matter and industry experts about the problem (for example, directors of quality or patient safety, nurse managers/directors, physicians, and epidemiologists).

To prepare for the assessment, complete the following:

• Identify the patient, family, or group you want to work with during your practicum The patient you select can be a friend or a family member. You’ll work with this patient, family, or group throughout your capstone project, focusing on a specific health care problem.
• Begin surveying the scholarly and professional literature to establish your evidence and research base, inform your assessment, and meet scholarly expectations for supporting evidence.

In addition, you may wish to complete the following:

• Review the assessment instructions and scoring guide to ensure that you understand the work you’ll be asked to complete and how it will be assessed.
• Review the Practicum Focus Sheet: Assessment 1 [PDF], which provides guidance for conducting this portion of your practicum.

Note: Remember that you can submit all, or a portion of, your draft assessment to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Instructions

Complete this assessment in two parts.

Part 1

Define the patient, family, or population health problem that will be the focus of your capstone project. Assess the problem from a leadership, collaboration, communication, change management, and policy perspective and establish your evidence and research base to plan, implement, and share findings related to your project.

Part 2

Connect with the patient, family, or group you’ll work with during your practicum. During this portion of your practicum, plan to spend at least 2 hours meeting with the patient, family, or group and, if desired, consulting with subject matter and industry experts of your choice. The hours you spend meeting with them should take place outside of regular work hours. Use the Practicum Focus Sheet [PDF] provided for this assessment to guide your work and interpersonal interactions. NURSFPX 4900 Capella University Nursing Global Health Concerns Essay

CORE ELMS

Complete the NURS-FPX4900 Volunteer Experience Form in CORE ELMS. Include a description of your relationship to the patient, family, or group in the Volunteer Experience comments field.

Requirements

The assessment requirements, outlined below, correspond to the scoring guide criteria, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, note the additional requirements for document format and length and for supporting evidence.

• Define a patient, family, or population health problem that’s relevant to your practice.
  • Summarize the problem you’ll explore.
  • Identify the patient, family, or group you intend to work with during your practicum.
  • Provide context, data, or information that substantiates the presence of the problem and its significance and relevance to the patient, family, or population.
  • Explain why this problem is relevant to your practice as a baccalaureate-prepared nurse.
• Analyze evidence from peer-reviewed literature and professional sources that describes and guides nursing actions related to the patient, family, or population problem you’ve defined.
  • Note whether the authors provide supporting evidence from the literature that’s consistent with what you see in your nursing practice.
  • Explain how you would know if the data are unreliable.
  • Describe what the literature says about barriers to the implementation of evidence-based practice in addressing the problem you’ve defined.
  • Describe research that has tested the effectiveness of nursing standards and/or policies in improving patient, family, or population outcomes for this problem.
  • Describe current literature on the role of nurses in policy making to improve outcomes, prevent illness, and reduce hospital readmissions.
  • Describe what the literature says about a nursing theory or conceptual framework that might frame and guide your actions during your clinical practicum.
• Explain how state board nursing practice standards and/or organizational or governmental policies could affect the patient, family, or population problem you’ve defined.
  • Describe research that has tested the effectiveness of these standards and/or policies in improving patient, family, or population outcomes for this problem. NURSFPX 4900 Capella University Nursing Global Health Concerns Essay
  • Describe current literature on the role of nurses in policy making to improve outcomes, prevent illness, and reduce hospital readmissions.
  • Describe the effects of local, state, and federal policies or legislation on your nursing scope of practice, within the context of this problem.
• Propose leadership strategies to improve outcomes, patient-centered care, and the patient experience related to the patient, family, or population problem you’ve defined.
  • Discuss research on the effectiveness of leadership strategies.
  • Define the role that you anticipate leadership must play in addressing the problem.
  • Describe collaboration and communication strategies that you anticipate will be needed to address the problem.
  • Describe the change management strategies that you anticipate will be required to address the problem.
• Organize content so ideas flow logically with smooth transitions.
• Apply APA style and formatting to scholarly writing.

Additional Requirements

• Format: Format your paper using APA style. Use the APA Style Paper Template. An APA Style Paper Tutorialis also provided to help you in writing and formatting your paper. Be sure to include:
  • A title page and reference page. An abstract is not required.
  • A running head on all pages.
  • Appropriate section headings.
• Length: Your paper should be approximately 5–7 pages in length, not including the reference page.
• Supporting evidence: Cite at least five sources of scholarly or professional evidence that support your central ideas. Resources should be no more than five years old. Provide in-text citations and references in APA format.

RESOURCES: LEADERSHIP

The following article provides an in-depth review of the effect of transformational leadership in nursing:

• Fischer, S. A. (2016). Transformational leadership in nursing: A concept analysis.Journal of Advanced Nursing, 72(11), 2644–2653.

The following article presents a mental model of effective health care leadership competencies, using a concept mapping approach:

• Hargett, C. W., Doty, J. P., Hauck, J. N., Webb, A. M. B., Cook, S. H., Tsipis, N. E., Neumann, J. A., Andolsek, K. M., & Taylor, D. C. (2017). Developing a model for effective leadership in healthcare: A concept mapping approach.Journal of Healthcare Leadership, 9, 69–78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774455/

The following article presents a comprehensive review of the literature related to decision making in nursing:

• Nibbelink, C. W., & Brewer, B. B. (2018). Decision-making in nursing practice: An integrative literature review.Journal of Clinical Nursing, 27(5/6), 917–928.

Watch the following videos:

• Preparing Nurses to Lead in a Changing Healthcare Environment.
  • This video presents strategies that an RN-to-BSN–prepared nurse can employ to lead and address health care problems.
• Principles of Crucial Conversations.
  • This video explores how to successfully address conflict in the workplace and address health care problems with a patient and family.
• Psychology of Change Framework.
  • This video depicts the effect of change on nursing and health care.

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Health Policies:

This website provides a search function to assist you in finding individual state nurse practice acts.

• National Council of State Boards of Nursing. (n.d.). Find your nurse practice act. https://www.ncsbn.org/npa.htm

Health Issues:

Use the following resources to begin exploring patient, family, or population health problems that you might choose as the focus of your capstone project. They provide information on a number of problems common to today’s health care systems. NURSFPX 4900 Capella University Nursing Global Health Concerns Essay

• Bindman, A. (2016). AHRQ’s role in improving care for patients with multiple chronic conditions.https://www.ahrq.gov/news/blog/ahrqviews/ahrqs-role-in-improving-care.html
  • This blog post focuses on patient-centered care for individuals with complex care needs.
• Centers for Medicare & Medicaid Services. (2016). CMS releases guide to preventing readmissions among racially and ethnically diverse Medicare beneficiaries.https://www.cms.gov/newsroom/press-releases/cms-releases-guide-preventing-readmissions-among-racially-and-ethnically-diverse-medicare
  • This press release discusses the CMS Guide to Reducing Disparities in Readmissions and includes links to the guide and additional information about readmissions that you may choose to review.
  • Joint Commission.(n.d.). http://www.jointcommission.org
    • The Joint Commission website provides resources addressing a variety of health care problems, any one of which you may want to choose as the focus of your capstone project.
  • Leapfrog Group.(n.d.). https://www.leapfroggroup.org/
    • The Leapfrog Group website provides data on hospital performance for a variety of services and patient outcomes. The data presented focus on common health care problems. Hospitals are graded on how well these problems are addressed. You may want to choose one of these problems as the focus of your capstone project.
  • Wang, Y., Kung, L., Gupta, S., & Ozdemir, S. (2019). Leveraging big data analytics to improve quality of care in healthcare organizations: A configurational perspective. British Journal of Management, 30(2), 362–388.
    • This article explores the use big data analytics (BDA) in addressing health care financial performance. Data are used to identify problems in health care, drive decisions about how to address these problems, and monitor the success of associated solutions. Think about how you can use data to identify the focus of your capstone project, determine an intervention, and measure the success of the solution. NURSFPX 4900 Capella University Nursing Global Health Concerns Essay

Case Study: Schizophrenia Answer Sheet

Case Study: Schizophrenia Answer Sheet

Case Study: Schizophrenia Answer Sheet

Student Name:

Diagnosing Randy:

1. Go to the DSM-IV checklist for schizophrenia and list each of Randy’s behaviors that satisfy the symptom criteria for schizophrenia. Which of Randy’s symptoms meet any of the criteria? (Be sure to match specific symptoms with specific criteria.)

2. How long has Randy been experiencing symptoms that meet the criteria for schizophrenia?

3. What type of schizophrenia does Randy display?

4. What phase of schizophrenia was Randy in during the days before the diner incident?

5. What phase was he in at the time of the diner incident that led to his arrest?

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Explaining Randy’s Schizophrenia:

1. What genetic factors may have played a part in Randy’s schizophrenia?

2. What biochemical abnormalities might account for Randy’s symptoms?

3. What might have been the role of family stress in Randy’s disorder?

4. What sociocultural factors may have played a role in Randy’s schizophrenia? Case Study: Schizophrenia Answer Sheet

Treating Randy:

1. Assume that instead of being jailed for his offenses, Randy is referred to a community health center for treatment planning. You are assigned to be his caseworker. What kind of assessments will you need to do before you begin Randy’s treatment planning?

2. What type of medication might you recommend for Randy?

3. What mental health treatment modalities would be helpful to Randy in addition to medication?

4. What services other than mental health treatment might be beneficial for Randy? Case Study: Schizophrenia Answer Sheet