Please be as detailed as possible.The patient information is attached as well as the template that must be used. Follow the rubric
Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses can piece together facts to construct a relevant history that can lead to assessment and treatment.
For this Focused Note Assignment, you will select a patient with common gynecologic health conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
- Use the Focused SOAP Note Template found in this week’s Learning Resources to complete this Assignment.
- select a patient with common gynecologic health conditions whom you examined during the last three weeks in your practicum experience. With this patient in mind, address the following in your Focused Note Template:
Assignment:
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- 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, 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.
- Reflection notes: What would you do differently in a similar patient evaluation?
PRAC 6552 Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”
HPI: 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 African American female). 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; Naproxen makes it tolerable but not completely better
Severity: 7/10 pain scale
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. Provide a description of the allergy (e.g., angioedema, anaphylaxis). This will help determine an actual reaction versus intolerance.
PMHx: Include current immunization status (for example date of the last tetanus and, human papilloma virus (HPV) vaccine), past significant illnesses, and surgeries. More information is sometimes needed, depending on the CC.
Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they always use seat belts or have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. The reason for the death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
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), intimate partner violence
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), Sexually active? Sexually transmitted infections (STIs). Types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.
ROS: covers all body systems that may help you include or rule out a differential diagnosis. You are ONLY to provide the ROS for the system(s) that pertain to your CC.
Examples of Focused ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
SKIN: No rash or itching. Breast lumps, pain, discharge?
GENITOURINARY: Burning on urination. No reports of vaginal discharge, or pain. No intermenstrual bleeding or spotting. No back or flank pain.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
O.
Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems 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:).Examples of possible systems are below.
General: Well appearing, well nourished, in no distress. Oriented x 3, everyday mood and affect. Ambulating without difficulty. Include VS- BP, HR, RR, Temp. Ht, Wt, BMI.
Pelvic: External genitalia with symmetric labia, no visible lesions. Labia majora and minora are without erythema or masses. Clitoris is normal in appearance. Perineum intact with no visible tears or scarring. No tenderness noted upon palpation of the external genitalia. Vagina and cervix without lesions or discharge. No cervical motion tenderness. Uterus, smooth, appropriate size, mobile, non- tender, and adnexa (ovaries) /parametria nontender without masses.
Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or supraclavicular adenopathy.
Diagnostic results: Include any labs, x-rays, or other diagnostics needed to develop the differential diagnoses (support with evidence and guidelines).
A.
Primary and Differential Diagnoses (list a minimum of 3 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.
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 be followed in an orderly manner. The reflection is also included in this section. The student should reflect on this case and discuss whether they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Also include a discussion related to health promotion and disease prevention in your reflection, considering patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background). Include how non-medical conditions (Social Determinants of Health) e.g., access to basic needs such as safety, transportation, food, and housing affect (actually or potentially) affect the plan of care.
References
You must include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines related to this case to support your diagnostics and differential diagnoses. Be sure to use correct APA 7th edition formatting.
