Focused SOAP Note Template Paper

Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S (subjective)

CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”). Focused SOAP Note Template Paper

HPI (history of present illness): 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
  

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Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus 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 and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and 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 possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Focused SOAP Note Template Paper

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).

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 (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:

• General:
• Head:
• EENT (eyes, ears, nose, and throat):
• :

Note: 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. Last menstrual period (LMP), MM/DD/YYYY.

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.

PSYCHIATRIC: No history of depression or anxiety.

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

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active. Focused SOAP Note Template Paper

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

O (objective)

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).

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

A (assessment)

Differential diagnoses: List a minimum of three differential diagnoses. Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

P (plan)

Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, 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.

Also included in this section is the reflection. Reflect on this case, and discuss what you learned, including any “aha” moments or connections you made.

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).

References

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.

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?
• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
• Provide 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 they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.  Focused SOAP Note Template Paper 

Case Study 1:

HPI: Ms. Peters is a 70-year-old female who is brought to your office by her son with reports of acute confusion (more than usual) and some agitation and restlessness. She has a known history of dementia, managed with Aricept 10 mg. daily. Her son, Jared, reports that 2 days ago she began to become more confused than usual and very easily agitated. He reports that yesterday, she couldn’t remember where she was in her own home. She had a doctor’s appointment 3 days ago and her HCTZ (hydrochlorothiazide) was increased to 50 mg. due to increased bp’s.

Ms. Peter’s last Mini-Mental State Exam (MMSE) score was 18/30. The assessment was repeated, and the score remained unchanged.

Ms. Peters and her son denies her having any falls or contributing traumas recently. She denies any changes in diet or routine regimens. No reported dysuria, no fever, nausea, or vomiting.

Note: Be sure to review the MMSE and how to interpret results (Mental State Assessment Tests). Make sure you document the patient’s score in your SOAP note document. Also review the Geriatric Depression Assessment (Geriatric Depression Scale [GDS]).

Ms. Peters is a 70-year-old female who is alert but easily distracted, at times, during today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert but disoriented to place and time. She denies any falls, denies any pain. Her son does say she has had some “stumbling” and balance issues but no reported falls.

All other Review of System and Physical Exam findings are negative other than stated.

Vital Signs: 98.1 120/64 HR-72 20

PMH: Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis

Allergies: Atorvastatin

Medications:

• Multivitamin daily
• Losartan 50mg daily
• HCTZ 50mg daily
• Fish Oil 1 tablet daily
• Glyburide 5mg daily
• Metformin 500mg BID
• Donepezil 10mg daily
• Alendronate 70mg orally once a week

Social History: As stated in Case Study

ROS: As stated in Case study

Diagnostics/Assessments done:

1. CXR—no cardiopulmonary findings. WNL
2. CT head—diffuse Cerebral Atrophy
3. MMSE—Ms. Peters scored 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall at a previous visit. At today’s visit, there is no change. Focused SOAP Note Template Paper. The score suggests moderate dementia.
4. Hemoglobin A1C7.2%
5. Basic Metabolic Panel as shown below

TEST	RESULT	REFERENCE RANGE
GLUCOSE	90	65–99
SODIUM	130	135–146
POTASSIUM	3.4	3.5–5.3
CHLORIDE	104	98–110
CARBON DIOXIDE	29	19–30
CALCIUM	9.0	8.6–10.3
BUN	20	7–25
CREATININE	1.00	0.70–1.25
GLOMERULAR FILTRATION RATE (eGFR)	77	>or=60 mL/min/1.73m2

 

 

 

See below sample in yellow – Please do not make it equal as this below is from other student.

Patient Information:

Ms. P., 70-year-old, Female, White

S

Chief Complaint: Ms. Peters comes into the office with her son due to worsening confusion,

agitation, and restlessness.

History of Present Illness: Ms. Peters is a 70-year-old female who comes to the clinic

accompanied by her son, Jared, with reports of worsening confusion, some agitation, and

restlessness. Jared recalls that two days ago, her mom became more confused than usual and gets

agitated quickly. He states that her mom could not remember where she was at her home

yesterday. He added that her mom was seen by her doctor three days ago, and her HCTZ

(hydrochlorothiazide) was increased to 50 mg due to elevated blood pressure. Focused SOAP Note Template Paper

Current Medications:

Multivitamin daily

Losartan 50 mg 1 tablet daily

HCTZ 50 mg 1 tablet daily

Fish Oil 1 tablet daily

Glyburide 5 mg daily

Metformin 500 mg 1 tablet BID

Donepezil 10 mg 1 tablet daily

Alendronate 70 mg 1 tablet orally once a week

Allergies:

Atorvastatin

Past Medical History:

Dementia, Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis

Immunizations: will obtain records

Social History: Lives at home with son. Denies tobacco and drug use.

Family History: No surgical history was reported.

Mental History: She has a history of dementia. She denies any visual or auditory

hallucinations. She denies any suicidal thoughts or ideation. Confusion more than usual 2 days

ago.

Violence History: She denies any issues about personal, home, community, and sexual violence.

Reproductive History: Postmenopausal

Review of Systems:

 General: No fever, chills, weakness, fatigue, or weight loss.

 Head: Denies any head injury or trauma.

 Eye: No blurry vision, double vision, or visual loss. No eye pain.

 Ears, Nose, Throat: No loss or changes in hearing, ringing, and discharges. Reports

balance issues and stumbling as noted by sob. No sneezing, congestion, runny nose, or

sore throat.

 Skin: No rash or itching.

 Cardiovascular: No chest pain, chest pressure or discomfort. No palpitations or leg

edema.

 Genitourinary: No dysuria, hematuria, polyuria, or nocturia. No breast changes, lumps,

and discharges. No history of breast cancer. Unknown mammogram history.

 Musculoskeletal: No muscle weakness, back pain, joint pain or stiffness. Denies any

falls. Some stumbling and balance issues as reported by her son.

 Neurological: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling

in the extremities. Memory changes reported by son. No history of stroke.

 Hematologic: No anemia, bleeding, or bruising. No blood transfusion and clotting

disorders reported.

 Lymphatics: No enlarged nodes or history of splenectomy.

 Pshychiatric: No history of depression or anxiety. Denies any visual or auditory

hallucinations. No suicidal thoughts or ideations. History of dementia.

 Endocrinologic: No sweating, cold, or heat intolerance. History of diabetes.

 Reproductive: Postmenopausal. No vaginal discharge.

 Allergies: No history of asthma, hives, eczema. Has history of chronic allergic rhinitis.

Reports allergy to Atorvastatin.

O

Physical Exam:

General: Alert but disoriented to time and place. Appropriately dressed, well-groomed and

appears well nourished. Speech is clear and coherent but easily distracted. Limited eye contact.

Vital Signs: BP: 120/64 HR: 72, regular R&R RR: 20, unlabored Temp: 98.1

HEENT:

Head: Normocephalic and no signs of injury or trauma. Intact facial sensation.

Eyes: Pupils equal, round, and reactive to light and accommodation. No redness or exudate. Eye

brows symmetrical.

Ears: Symmetrical. No swelling noted. No discharges. Tympanic membrane intact with no

erythema.

Nose: Symmetrical. No nasal deviation, nasal flaring polyps noted.

Throat: No erythema noted or exudates noted. Gag reflex intact.

Neck: Supple with full range of motion. No masses palpated. No tracheal deviation noted.

Respiratory: Clear lungs in all lung fields to auscultation with inspiration and expiration.

Bilateral chest with equal rise and fall on inspiration and expiration.

Cardiovascular: Heart rate 72, regular rate and rhythm, S1 and S2 noted. No murmurs, gallops,

and rubs. No bruits noted on abdominal aorta. Peripheral pulses intact. No edema noted.

Gastrointestinal: Abdomen soft, non-tender. Active bowel sounds in all quadrants.

Genitourinary: Bladder not distended.

Musculoskeletal: Fully weight bearing with some gait disturbances noted. Full ROM to upper

extremities, spine, hips, and lower extremities.

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Integumentary: No significant rash or lesions observed. Skin color appropriate for age. Skin

warm to touch with skin turgor appropriate for age.

Neurologic: CN II – XII grossly intact. Noted some gait and balance disturbances. No unusual

movements or tics noted. Sensations on both arms and legs intact. Deep tendon reflex to lower

and upper extremities 2+.

Psychiatric: Mood and affect are appropriate but appears easily distracted.

Hematologic: No bruising or discoloration noted on exam.

Lymphatics: No enlarged lymph nodes palpated.

Diagnostic results:

1. CXR – No cardiopulmonary findings. Within normal limits.
2. CT Head – Diffuse cerebral atrophy.
3. MMSE – Score 18/30 with primary deficits in orientation, registration, attention, and

calculation, and recall at a previous visit. No changes in today’s visit. Score suggests

moderate dementia. Focused SOAP Note Template Paper

4. Labs – Hemoglobin A1C 7.2 %
5. Basic Metabolic Panel –

TEST RESULT REFERENGE RANGE

Glucose 90 65-99

Sodium 130 135-146

Potassium 3.4 3.5-5.3

Chloride 104 98-110

Carbon dioxide 29 19-30

Calcium 9.0 8.6-10.3

BUN 20 7-25

Creatinine 1.0 0.72-1.25

GFR 77 >or=60 ml/min/1.73m2

A

Differential diagnoses:

1. Dementia

Dementia is a clinical condition characterized with a cognitive decline from a previous level of

baseline function that interferes with activities of daily living (ADLs) (Kennedy-Malone, MartinPlank, & Duffy, 2019). Age is the most significant risk factor for dementia with prevalence rate

doubling every five years from the age of 65-85 (Dening and Aldridge, 2021). Ms. Peters showed

signs of confusion, worse than her baseline as indicated by her inability to recognize where she

was in her own home. She also has a history of dementia. Her MMSE score of 18/30 confirms

this primary diagnosis. dementia (Myrberg et al., 2020). The patient’s MMSE score suggest

moderate dementia. The MMSE is an 11-question tool that tests five areas of cognitive function:

orientation, registration, attention and calculation, recall and language (Laske & Stephens, 2018).

The perfect score is 30, with a score of 23 and lower indicates cognitive impairment (Laske &

Stephens, 2018). Advanced age, recent memory impairment, and changes in personality –

agitation and restlessness, are positive indicators of dementia.

2. Depression

Depression in elderly patients is a common disorder that affect their quality of life. Depression

contributes to adverse functional and social outcomes of the said population. Acute confusion

that was worse than baseline, agitation, and restlessness are positive indicators for depression.

Confusion or attention problems due to depression may also be attributed to AD, dementia, or

other brain disorders (National Institute on Aging, 2020); thus, it is crucial to rule out depression

to determine the primary diagnosis. The Geriatric Depression Scale is a self-rated questionnaire,

available in long form (30 items) and a short-form version (15 items) for diagnosing depression

with a cutoff score of eleven in the long form and seven points in the short form (Blackburn et

al., 2017). The reliability, however, decreases with increasing cognitive impairment. The said

screening tool will be included in the plan to rule out the diagnosis of depression.

3. Alzheimer’s Disease (AD)

AD is type of dementia that is characterized by a progressive loss of episodic memory and

cognitive function, which later causes deficiencies in language and visuospatial skills, and often

accompanied by behavioral disorders such as aggressiveness, apathy, and depression (Silva et al.,

2019). In assessing Mrs. Peters was reported to have stumbling and balance issues. This could be

an indication of a decline in visuospatial skills, indicating AD. Agitation and restlessness were

also noted with the patient which are positive indicators associated with AD. Current tests

performed does not confirm this diagnosis, thus, tests to check for biomarkers of cerebrospinal

fluid and positron emission 10 tomography in combination with several relatively new clinical

criteria can aid in confirming this diagnosis.

Plan

1. Order additional diagnostic studies.
2. Complete blood count and urinalysis can help rule out infections that may be causing

the changes in cognition.

1. Cerebrospinal fluid analysis will be ordered to rule out any specific infections affecting

the brain.

1. Toxicology screens for drug and alcohol use will also determine if the patient’s

behavior is related to controlled substances. Focused SOAP Note Template Paper

1. Magnetic Resonance Imaging (MRI) – can exclude potentially reversible dementia

causes such as hydrocephalus, subdural hematoma, stroke, and intra and extra-axial tumors

(Panegyres et al., 2016). The CT scan shows diffuse cerebral atrophy, but MRI has a higher

resolution that can detect subtle and anatomical and vascular changes.

1. Repeat Hemoglobin A1C in 3 months. Current result shows inadequate control of

blood sugar which may be contributing to the changes in the patient’s cognitive and functional

skills.

1. Perform Geriatric Depression Scale to determine depression.
2. Therapeutic interventions:
3. Continue Donezepil 10 mg tablet daily. Donezepil, a cholinesterase inhibitor, is the

recommended therapy for mild, moderate, or severe AD dementia (Panegyres et al., 2016).

1. Discontinue Glyburide component in the management of delirium, dementia, and AD.

The American Geriatrics Society Beers Criteria identifies medications to avoid in geriatric

patients. The Beers criteria strongly recommends glyburide to be avoided in older adults due to

higher risk of severe prolonged hypoglycemia (Al-Azayzih et al., 2019). Hypoglycemia can alter

a patient’s level of alertness. A fall in blood sugar can cause confusion, which was one of Mrs.

Peter’s presenting symptoms. Continue Metformin.

1. Continue the rest of her current medications to maintain control of blood pressure and

diabetes.

3. Refer patient for psychiatric evaluation can help determine if delirium, depression or other

mental health condition is contributing to the patient’s symptoms.

4. Education: Health promotion tasks.
5. Proper nutrition to control diabetes and high blood pressure to improve overall health

and reduce risk of worsening neurodegenerative disease.

1. Physical exercise to preserve strength and prevent loss of agility associated with age

and decrease neuropsychiatric symptoms. Less brain atrophy was noted in patients with AD who

had regular exercise (Panegyres et al., 2016).

1. Offer availability of influenza vaccine to patient.
2. Establish a safe environment. The patient may need assistance with activities of daily

living.

5. Follow up in one week for reevaluation. Perform a repeat MMSE to check for worsening of

dementia or AD. For worsening of symptoms or if new acute symptoms appear, take patient to

the emergency department for evaluation and treatment.

Reflection

Evaluating the case study helped a clinician analyzing the importance of obtaining an

adequate information in performing a SOAP note. There are some information missing in the

subjective and objective assessments that could assist in the creation of the assessment and plan.

A recent study discussed that disparities in the prevalence of dementia was not statistically

different for whites, blacks, and Hispanics (Chena & Zissimopoulosa, 2018); however, it is

important to note that the combination of socioeconomic 13 and cultural factors can affect the

compliance of patients in treatment plans. Will need to obtain immunization history and

information regarding the history of eye exam, colonoscopy, pap smear, and mammogram were

not supplied. Annual health screenings will aid in discovering diseases before they worsen,

especially with elderly patients who have greater risks due to comorbidities associated with

advanced age. Medication reminder is important to older patients as well. It is important to know

when the patient last took her medications to evaluate compliance to therapy. Literature showed

that poor adherence in medication regimen include patients with many comorbidities and

cognitive impairment (Smaje et al., 2018). The patient’s HgbA1c was elevated and patient

showed signs of confusion in her visit. Medication compliance can determine if the patient’s

symptoms were dosage related or a compliance issue to taking her diabetic and dementia

medications. The case study also did not say about Mrs. Peter’s family history. Although family

history is not necessary to develop AD and other dementias, it is important to note that that when

they run in families, genetic factors, environmental factors, or both may play a role (Panegyres et

al., 2016). Safety concerns for patients with dementia, AD, and delirium would include

wandering, fall risks, and inability to perform activities of daily living; thus, the importance of a

good support system is vital to ensure their safety.

Conclusion

Psychosocial disorders in the geriatric population is prevalent and proper assessment and

management are necessary to preserve their functional abilities. As advanced practice nurses, it is

important to obtain adequate information to be able to develop appropriate treatment plans,

including diagnostics and laboratory orders, for patients with psychosocial disorders. With the

anatomical changes related to advanced age, mental function changes along with it.

Understanding what happens during the aging process will allow the practitioner differentiate

between symptoms that are normal and those considered abnormal. For the older adult, physical

health, mental health, spiritually, environmental and social problems interact to complicate the

life and function of the older patient, caregiver, and family.

References

Al-Azayzih, A., Alamoori, R., & Altawalbeh, S. M. (2019). Potentially inappropriate

medications prescribing according to Beers criteria among elderly outpatients in Jordan:

A cross-sectional study. Pharmacy Practice, 17(2), 1439. https://doi.org/

10.18549/PharmPract.2019.2.1439

Arevalo-Rodriguez, I., Smailagic, N., Roque-Fguls, M., Ciapponi, A., Sanchez-Perez, E.,

Giannakou, A., Pedraza, O. L., Bonfill-Cosp, X., & Cullum, S. (2015). Mini-mental state

examination for the detection of Alzheimer’s disease and other dementias in people with

mild cognitive impairment. Cochrane Database of Systematic Reviews, (3).

https://doi.org/ 10.1002/14651858.CD010783.pub2

Arvanitakis, Z., Shah, R. C., & Bennett, D. A. (2019). Diagnosis and management of dementia:

Review. Journal of the American Medical Association, 322(16), 1589- 1599.

https://doi.org/10.1001/jama.2019.4782

Blackburn, P., Wilkins-Ho, M., & Wiese, B. (2017). Depression in older adults: Diagnosis and

management. BC Medical Journal, 59(3), 171-177.

https://bcmj.org/articles/depressionolder-adults-diagnosis-and-management

Chena, C., & Zissimopoulosa, J. M. (2018). Racial and ethnic differences in trends in dementia

prevalence and risk factors in the United States. Alzheimers Dementia, 4, 510- 520.

https://doi.org/10.1016/j.trci.2018.08.009

Dening, K. H., & Aldridge, Z. (2021). Dementia: recognition and cognitive testing in primary

care settings. Journal of Community Nursing, 31(9), 43-49. Retrieved from

Kennedy-Malone, L., Martin-Planl, L., & Duffy, E. (2019). Advanced practice nursing in the

care of older adults (2nd ed.) F.A. Davis.

Laske, R. A. & Stephens, B. A. (2018). Confusion states: Sorting out delirium, dementia, and

depression. Nursing made incredibly made easy, 16(6), 13-16. Retrieved from doi:

10.1097/01.NME.0000546254.38666.1f

National Institute on Aging. (2020). Depression and older adults.

https://www.nia.nih.gov/health/depression-and-older-adults

Rosen, T., Connors, S., Clark, S., Halpern, A., Stern, M. E., DeWald, J., Lachs, M. S., &

Flomenbaum, N. (2015). Assessment and management of delirium in older adults in the

emergency department: Literature review to inform development of a novel clinical

protocol. Advance Emergency Nursing Journal, 37(3), 183– E3.

https://doi.org/10.1097/TME.0000000000000066

Silva, M. V., Loures, C. M., Alves, L. C., De Souza, L. C., Borges, K. B., & Carvalho, M. D.

(2019). Alzheimer’s disease: Risk factors and potentially protective measures. Journal of

Biomedical Science, 26(33). https://doi.org/10.1186/s12929-019-0524-y

Smaje, A., Weston-Clark, M., Raj, R., Orlu, M., Davis, D., & Rawle, M. (2018). Factors

associated with medication adherence in older patients: A systematic review. Aging

Medicine, 1(3), 254-266. https://doi.org/10.1002/agm2.12045

Myrberg, K., Hyden, L. C., & Samuelsson, C. (2020). The mini-mental state examination

(MMSE) from a language perspective: An analysis of test interaction. Clinical

Linguistics and Phonetics, 34(7), 652-670. https://doi.org/10.1080/02699206.2019.1687

Panegyres, P. K., Berry, R., & Burchell, J. (2016). Early dementia screening. Diagnostics, 6(1). Focused SOAP Note Template Paper

PEDS – Week 8 Clinical Case Report SOAP PowerPoint

For this assignment, you are to complete a clinical case – PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.  

You are to approach this clinical scenario as if it is a real patient in the clinical setting.

Instructions are in the word document attached and I also attached an example given by my professor.

For this assignment, you are to complete a clinical case – PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.  

You are to approach this clinical scenario as if it is a real patient in the clinical setting.

Instructions:

Step 1 – Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.

Step 2 – Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.

Step 3 – Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations. PEDS – Week 8 Clinical Case Report SOAP PowerPoint

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Example of Steps 1 – 3:

You decided on Angina after reading the clinical case scenario (Step 1)

Review of Symptoms (list of classic symptoms):

CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone

GI: indigestion, heartburn, nausea, cramping

Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth

Resp: shortness of breath

Musculo: weakness

 

Step 4 – Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations. PEDS – Week 8 Clinical Case Report SOAP PowerPoint

 

Example of Step 4:

You determined the patient has Angina in Step 1

Physical Examination (list of classic exam findings):

CV: RRR, murmur grade 1/4

Resp: diminished breath sounds left lower lobe

 

Step 5 – Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.

 

Step 6 – Develop a treatment plan for the diagnoses. Only use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan must address the following:

1. a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
2. b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
3. c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
4. d) Vaccines administered this visit & vaccine administration forms given,
5. e) Non-pharmacological treatments
6. f) Patient/Family education including preventive care
7. g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
8. h) Follow-up appointment with a detailed plan of f/u

 

As you develop your narrated PowerPoint, be sure to address the criteria discussed in the video above and the instructions listed below:

 

FOLLOW THE TEMPLATE BELOW for the Clinical Case Report – SOAP PowerPoint Assignment:

 

DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE.

 

SUBJECTIVE (S): Describes what the patient reports about their condition.

For INITIAL visits gather the info below from the clinical scenario and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION.

 

Historian (required; unless the patient is 16 y/o and older): document name and relationship of guardian

Patient’s Initials + CC (Identification and Chief Complaint): E.g. 6-year-old female here for evaluation of a palmar rash

HPI (History of Present Illness): Remember OLD CAARTS (onset, location, duration, character, aggravating/alleviating factors, radiation, temporal association, severity) written in paragraph form

PMH (Past Medical History): List any past or present medical conditions, surgeries, or other medical interventions the patient has had. Specify what year they took place. PEDS – Week 8 Clinical Case Report SOAP PowerPoint

MEDs: List prescription medications the patient is taking. Include dosage and frequency if known. Inquire and document any over-the-counter, herbal, or traditional remedies.

Allergies: List any allergies the patient has and indicate the reaction. e.g. Medications (tetracycline-> shortness of breath), foods, tape, iodine->rash

FH (Family History): List relevant health history of immediate family: grandparents, parents, siblings, or children. e.g. Inquire about any cardiovascular disease, HTN, DM, cancer, or any lung, liver, renal disease, etc…

SHx (Social history): document parent’s work (current), educational level, living situation (renting, homeless, owner), substance use/abuse (alcohol, tobacco, marijuana, illicit drugs), firearms in-home, relationship status (married, single, divorced, widowed), number of children in the home (in SF or abroad), how recently pt immigrated to the US and from what country of origin (if applicable), the gender of sexual partners, # of partners in last 6 mo, vaginal/anal/oral, protected/unprotected.

 

Patient Profile: Activities of Daily Living (age-appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.), Changes in daycare/school/after-school care, Sports/physical activity, and Developmental History: (provide a history of development over the child’s lifespan. If a child is 1y/o or younger, provide birth history also)

 

HRB (Health-related behaviors):

ROS (Review of Systems): Asking about problems by organ system systematically from head-to-toe. Included classic associated symptoms (this includes pertinent negatives and positives).

 

OBJECTIVE: Physical findings you observe or find on the exam.

1. Age, gender, general appearance
2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile; Weight & Percentile, Include the Growth Chart
3. Physical Exam: note pertinent positives and negatives (refer to the textbook for classic findings related to present complaint and the diagnosis you believe the patient has)
4. Lab Section – what results do you have?
5. Studies/Radiology/Pap Results Section – what results do you have?

 

RISK FACTORS: List risk factors for the acute and chronic conditions

 

ASSESSMENT: What do you think is going on based on the clinical case scenario? This is based on the case. You are to list the acute diagnosis and three differential diagnoses, in order of what is likely, possible, and unlikely (include supporting information that helped you to arrive at these differentials). You must include the ICD-10 codes, the definition for the acute and differential diagnoses, and the pertinent positives and negatives of each diagnosis.

 

You are to also list any chronic conditions with the ICD-10 codes.

 

NATIONAL CLINICAL GUIDELINES: List the guidelines you will use to guide your treatment and management plan

 

TREATMENT & MANAGEMENT PLAN: Number problems (E.g. 1. HTN, 2. DM, 3. Knee sprain), use bullet points, and include A – F below for each diagnosis and G – H after you’ve addressed all conditions.

 

Example:

1. HTN
2. a) Vaccines administered this visit & vaccine administration forms given,
3. b) Medication-include dosage amounts and mg/kg for drug and number of days,
4. c) Laboratory tests ordered
5. d) Diagnostic tests ordered
6. e) Non-pharmaceutical treatments
7. f) Patient/Family education including preventive care

 

2. HLD
3. a) Vaccines administered this visit & vaccine administration forms given,
4. b) Medication-include dosage amounts and mg/kg for drug and number of days,
5. c) Laboratory tests ordered
6. d) Diagnostic tests ordered
7. e) Non-pharmaceutical treatments
8. f) Patient/Family education including preventive care

Also discussed:

1. g) Anticipatory guidance for next well-child visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)

Return to the clinic:

1. h) Follow-up appointment with a detailed plan for f/u and any referrals

 

CLINICAL CASE SCENARIO

A mother brings her 18-month-old son to your clinic because of a persistent facial rash. The child is restless at night and scratches in her sleep. He is otherwise healthy. Today, his vitals are as follows: weight 23.4 lbs, height 31.8 inches, BP 120/76, HR 100, RR 26, and Temperature is 98.6 F. His physical examination reveals a well-nourished, healthy-appearing child with dry, red, scaly areas on the cheeks, chin, and around the mouth as well as on the extensor surfaces of his extremities. The areas on the cheeks have a plaque-like, weepy appearance. The diaper area is spared. The remainder of the child’s examination is normal. PEDS – Week 8 Clinical Case Report SOAP PowerPoint

Diagnosis – Atopic Dermatitis

 

Nurs 6052N_WK10_PART4_ Assigment5

The collection of evidence is an activity that occurs with an endgame in mind. For example, law enforcement professionals collect evidence to support a decision to charge those accused of criminal activity. Similarly, evidence-based healthcare practitioners collect evidence to support decisions in pursuit of specific healthcare outcomes.

In this Assignment, you will identify an issue or opportunity for change within your healthcare organization and propose an idea for a change in practice supported by an EBP approach. Nurs 6052N_WK10_PART4_ Assigment5

To Prepare:

• Reflect on the four peer-reviewed articles you critically appraised in Module 4, related to your clinical topic of interest and PICOT.
• Reflect on your current healthcare organization and think about potential opportunities for evidence-based change, using your topic of interest and PICOT as the basis for your reflection.
• Consider the best method of disseminating the results of your presentation to an audience.

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The Assignment: (Evidence-Based Project)

Part 4: Recommending an Evidence-Based Practice Change

Create an 8- to 9-slide narrated PowerPoint presentation in which you do the following:

• Briefly describe your healthcare organization, including its culture and readiness for change. (You may opt to keep various elements of this anonymous, such as your company name.)
• Describe the current problem or opportunity for change. Include in this description the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with change implementation in general.
• Propose an evidence-based idea for a change in practice using an EBP approach to decision making. Note that you may find further research needs to be conducted if sufficient evidence is not discovered.
• Describe your plan for knowledge transfer of this change, including knowledge creation, dissemination, and organizational adoption and implementation. Nurs 6052N_WK10_PART4_ Assigment5
• Explain how you would disseminate the results of your project to an audience. Provide a rationale for why you selected this dissemination strategy.
• Describe the measurable outcomes you hope to achieve with the implementation of this evidence-based change.
• Be sure to provide APA citations of the supporting evidence-based peer reviewed articles you selected to support your thinking.
• Add a lessons learned section that includes the following:
  • A summary of the critical appraisal of the peer-reviewed articles you previously submitted
  • An explanation about what you learned from completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template (1-3 slides) Nurs 6052N_WK10_PART4_ Assigment5

Reply to the following discussion by challenging the post. You will want to focus on their point of view, asking pertinent questions, adding to the responses by including information from other sources, and respectfully challenging a point of view, supported by references to other sources. Be objective, clear, and concise. Always use constructive language.  

It is important to support what you say with relevant citations in the APA format from both the course materials and outside resources. 

KR Discussion:

 

PICOT Question “ In older adults aged 65 years or older living in the community with diabetes (Population) does a nurse practitioner led evidence based health education program on diabetes self-management (Intervention) compared to current protocols (Control) increase diabetes self-management efficacy (Outcome) in a period of  4 months? (Time)”

1. Who will benefit from receipt of this evidence?

Two groups of people will benefit from this evidence. That is, primary care providers, (nurse practitioners), and registered nurses, as well as community residing older adults with diabetes. The evidence from the EBP will assist registered nurses and nurse practitioners in developing and implementing evidence based programs for improving diabetes self-management informed by current research. Nurse practitioners are skilled and trained to provide care in population groups across all ages, and are crucial in implementing evidence based preventive interventions and chronic disease management such as diabetes (Woo et al., 2017). Nursing homework help

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1. Where will this evidence have the greatest impact?

The evidence will greatly impact diabetes self-management efficacy for older community dwelling adults that are at elevated risks for diabetes associated poor health outcome and complications due to specific risk factors such as low social support, pre-existing conditions, inadequate diabetes self-management knowledge and low health services utilization (Kalyani et al., 2017).

1. What resources are needed?

Being a health education based type of EBP, the program is relatively inexpensive and includes costs for education materials such as posters, brochures, and hiring of venue for administering health education.  Technology for projection educational material s may also increase costs.

1. Who is the most appropriate audience?

Nurse practitioners, registered nurses, home based care givers.

1. What are the benefits of this evidence to your selected audience?

Sharing of the evidence will improve diabetes self-management efficacy in community dwelling older adults thus reducing the burden of mortality, comorbidity, and associated treatment costs (Kalyani et al., 2017). Nursing homework help

1. What are the potential risks of failing to disseminate this evidence?

When left unmanaged, type 2 diabetes can cause various forms of serious health complications that are categorized as micro vascular and macro vascular. Micro vascular complications of type 2 diabetes entail nervous system disorders (neuropathy), damage to the renal system (nephropathy), and eyesight complications (retinopathy)  (Kalyani et al., 2017). Common macro vascular complications for type 2 diabetes  are cardiovascular diseases , heightened chances of stroke,  and peripheral vascular diseases that  are characterized by amputations originating from  non-healing  surface injuries and gangrene(Kalyani et al., 2017).Diabetes also puts a huge cost burden to the health system  making self-management desirable. Failure to disseminate the evidence from the EBP translates to missed opportunities of reducing diabetes health and cost burdens in community dwelling older adults.

1. What are the barriers to dissemination of evidence?

According to Kreuter and Wang (2016), major barriers in dissemination of evidence can be traced to inappropriate audience choice, poor communication strategy, and limitations in dissemination mediums or methods. The major barrier in evidence dissemination for this project is access to the vital audience, and difficulty in identifying an appropriate mode of dissemination due to the large volume of information involved.

The preferred mode of dissemination is a PowerPoint presentation. PowerPoint allows collaborative presentations of data with multiple uses that enhances effective way of communication with the audience through various designs as well as facilitating exportation to different formats (Shigli et al., 2016).

References

Kreuter, M. W., & Wang, M. L. (2016). From evidence to impact: Recommendations for a dissemination support system. New Directions for Child and Adolescent Development, 2015(149), 11-23. https://doi.org/10.1002/cad.20110

Kalyani, R. R., Golden, S. H., & Cefalu, W. T. (2017). Diabetes and aging: Unique considerations and goals of care. Diabetes Care, 40(4), 440-443. https://doi.org/10.2337/dci17-0005

Shigli, K., Agrawal, N., Nair, C., Sajjan, S., Kakodkar, P., & Hebbal, M. (2016). Use of PowerPoint presentation as a teaching tool for undergraduate students in the subject of gerodontology. The Journal of Indian Prosthodontic Society, 16(2), 187. https://doi.org/10.4103/0972-4052.167940

Woo, B. F., Lee, J. X., & Tam, W. W. (2017). The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review. Human Resources for Health, 15(1). https://doi.org/10.1186/s12960-017-0237-9

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Certification and Licensure Plan Assignment

Certification and Licensure Plan

locate and review the practice agreements in Maryland, identify potential collaboration requirements in the MD, and understand the certification and licensing process that is needed to follow.

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1. Identify whether this state requires physician collaboration or supervision for nurse practitioners, and if so, what those requirements.
2. How do you get certified and licensed as an Advanced Practice Registered Nurse (APRN) and as a PMHNP in the state of Maryland?
3. What is the application process for certification in this state?
4. What is the state’s board of nursing website?
5. How does this state define the scope of practice of a nurse practitioner?
6. What is included in the state practice agreement?
7. How do you get a DEA license in this states?
8. Does Maryland have a prescription monitoring program (PMP)?
9. How does Maryland describe a nurse practitioner’s controlled-substance prescriptive authority, and what nurse practitioner drug schedules are nurse practitioners authorized to prescribe?
10. Explain the types of regulations that exist and the barriers that may impact nurse practitioner independent practice in the state of Maryland. Be specific.
11. Describe what surprised you from your research.

*****Please address all questions thoroughly in a essay format. Written clearly and concisely and use of scholarly sources to support ideas demonstrates. Certification and Licensure Plan Assignment