Assessing and managing a patient

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Assignment 2: Practicum – SOAP Note and Time Log

Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

· Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies. Assessing and managing a patient 

· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.

· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

· Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

By Day of Week 7

You will submit this Week 7 SOAP Note along with your Journal Entries (from Weeks 5, 6, and 7) and Practicum Time Log.

Practicum – Journal Entry

Reflect on a patient who presented with cardiovascular or genetic disorders during your Practicum experience. Describe your experience in assessing and managing the patient and his or her family. Include details of your “aha” moment in identifying the patient’s disorder. Then, explain how the experience connected your classroom studies to the real-world clinical setting. If you did not have an opportunity to evaluate a patient with this background during the last 8 weeks, you may select a related case study from a reputable source or reflect on previous clinical experiences. Assessing and managing a patient

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By Day 7 of Week 7

Please submit the Journal Entries (Weeks 5, 6, and 7) and the Week 7 SOAP Note by Day 7 of Week 7 (this week).

Note:  Be sure to submit your Assignment to the appropriate submission link below.

Submissions should match the following:

· Week 7 SOAP Note: Submit to the Assignment 2 Turnitin Part 1 – Week 7 submission link.

· Week 5, 6, & 7 Journal Entry: Submit to the Assignment 2 Turnitin Part 2 – Week 7 submission link.

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

· Please save your Assignment 2 using the following naming convention: “WK7Assgn2PTX+lastname+first initial”.

· Click the Week 7 Assignment 2 Part X link.

· Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK7Assgn2PTX+last name+first initial.(extension)” and click Open. If you are submitting multiple files, repeat until all files are attached.

· Click on the Submit button to complete your submission.

Name: NURS_6541_Week7_Application1_Rubric

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  Excellent Good Fair Poor
Quality of Work Submitted: The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking. 27 (27%) – 30 (30%)Assignment exceeds expectations. All topics are addressed with a minimum of 75% containing exceptional breadth and depth about each of the assignment topics. 24 (24%) – 26 (26%)Assignment meets expectations. All topics are addressed with a minimum of 50% containing goodbreadth and depth about each of the assignment topics. 21 (21%) – 23 (23%)Assignment meets most of the expectations. One required topic is either not addressed or inadequately addressed. 0 (0%) – 20 (20%)Assignment superficially meets some of the expectations. Two or more required topics are either not addressed or inadequately addressed.
Quality of Work Submitted: The purpose of the paper is clear. 5 (5%) – 5 (5%)A clear and comprehensive purpose statement is provided which delineates all required criteria. 4 (4%) – 4 (4%)Purpose of the assignment is stated, yet is brief and not descriptive. 3.5 (3.5%) – 3.5 (3.5%)Purpose of the assignment is vague or off topic. 0 (0%) – 3 (3%)No purpose statement was provided.
Assimilation and Synthesis of Ideas: The extend to which the work reflects the student’s ability to: Understand and interpret the assignment’s key concepts. 9 (9%) – 10 (10%)Demonstrates the ability to critically appraise and intellectually explore key concepts. Assessing and managing a patient  8 (8%) – 8 (8%)Demonstrates a clear understanding of key concepts. 7 (7%) – 7 (7%)Shows some degree of understanding of key concepts. 0 (0%) – 6 (6%)Shows a lack of understanding of key concepts, deviates from topics.
Assimilation and Synthesis of Ideas: The extend to which the work reflects the student’s ability to: Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources. 18 (18%) – 20 (20%)Demonstrates and applies exceptional support of major points and integrates 2 or more credible outside sources, in addition to 2-3 course resources to suppport point of view. 16 (16%) – 17 (17%)Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view. 14 (14%) – 15 (15%)Minimally includes and integrates specific information from 2-3 resources to support major points and point of view. 0 (0%) – 13 (13%)Includes and integrates specific information from 0 to 1 resoruce to support major points and point of view.
Assimilation and Synthesis of Ideas: The extend to which the work reflects the student’s ability to: Synthesize (combines various components or different ideas into a new whole) material in course resources (i.e. video, required readings, textbook) and outside, credible resources by comparing different points of view and highlighting similarities, differences, and connections. 18 (18%) – 20 (20%)Synthesizes and justifies (defends, explains, validates, confirms) information gleaned from sources to support major points presented. Applies meaning to the field of advanced nursing practice. 16 (16%) – 17 (17%)Summarizes information gleaned from sources to support major points, but does not synthesize. 14 (14%) – 15 (15%)Identifies but does not interpret or apply concepts, and/or strategies correctly; ideas unclear and/or underdeveloped. 0 (0%) – 13 (13%)Rarely or does not interpret, apply, and synthesize concepts, and/or strategies.
Written Expression and Formatting Paragraph and Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance. 5 (5%) – 5 (5%)Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity 4 (4%) – 4 (4%)Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity 80% of the time. 3.5 (3.5%) – 3.5 (3.5%)Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity 60%- 79% of the time. 0 (0%) – 3 (3%)Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity < 60% of the time.
Written Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%)Contains a few (1-2) grammar, spelling, and punctuation errors. 3.5 (3.5%) – 3.5 (3.5%)Contains several (3-4) grammar, spelling, and punctuation errors. 0 (0%) – 3 (3%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list. Assessing and managing a patient  5 (5%) – 5 (5%)Uses correct APA format with no errors. 4 (4%) – 4 (4%)Contains a few (1-2) APA format errors. 3.5 (3.5%) – 3.5 (3.5%)Contains several (3-4) APA format errors. 0 (0%) – 3 (3%)Contains many (≥ 5) APA format errors.
Total Points: 100