PRAC 6552 Episodic Visit: Gynecology Focused Note

PRAC 6552 Episodic Visit: Gynecology Focused Note

Episodic Visit: Gynecology Focused Note

  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 gynecologic 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.

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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

 

Learning Resources

Required Readings

  • Fowler, G. C. (2019). Pfenninger and Fowler’s Procedures for Primary Care (4th ed.). Elsevier.
    • Chapter 136, “Insertion and Removal of Nexplanon” (pp. 946–951)
    • Chapter 137, “Pessaries” (pp. 952–959)
    • Chapter 138, “Treatment of Noncervical Condylomata Acuminata” (pp. 960–969)
    • Chapter 139, “Vulvar Biopsy” (pp. 970–973)

Practicum Resources 

Links to an external site. (n.d.-a).?Field experience: College of Nursing.

  • Links to an external site.. https://edu.meditrek.com/Default.html
    Note: Use this website to log in to Meditrek to report your clinical hours and patient encounters.

Clinical Guideline Resources 

  • As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for the CDC -zika in pregnancy, etc.).

To prepare:

  • Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.
  • Select a patient that you examined during the last three weeks. 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?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 3.

By Day 7

Submit your Focused Note Assignment. (Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 3.)

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

  1. To submit your completed assignment, save your Assignment as WK3Assgn2_LastName_Firstinitial
  2. Then, click on Start Assignment near the top of the page.
  3. Next, click on Upload File and select Submit Assignment for review.

Rubric

PRAC_6552_Week3_Assignment2_Rubric

PRAC_6552_Week3_Assignment2_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning Outcome Create documentation in the Focused SOAP Note Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications• Allergies• Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history• Review of systems 10 to >8.0 pts Excellent The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

8 to >7.0 pts Good The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

7 to >6.0 pts Fair The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.

6 to >0 pts Poor The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.

 10 pts
This criterion is linked to a Learning Outcome In the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses 10 to >8.0 pts Excellent The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

8 to >7.0 pts Good The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

7 to >6.0 pts Fair Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

6 to >0 pts Poor The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.

 10 pts
This criterion is linked to a Learning Outcome In the Assessment section, provide: • At least 3 differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. 25 to >22.0 pts Excellent The response lists at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.

22 to >19.0 pts Good The response lists at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.

19 to >17.0 pts Fair The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

17 to >0 pts Poor The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

 25 pts
This criterion is linked to a Learning Outcome In the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. 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.• Reflections on the case describing insights or lessons learned. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. 30 to >26.0 pts Excellent The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. A thorough and accurate disucssion of health promotion and disease prevention related to the case is provided.

26 to >23.0 pts Good The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate critical thinking. An accurate disucssion of health promotion and disease prevention related to the case is provided.

23 to >20.0 pts Fair The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. Reflections on the case demonstrate adequate understanding of course topics. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies.

20 to >0 pts Poor The response does not address all diagnoses or is missing elements of the treatment plan. Reflections on the case are vague or missing. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing.

 30 pts
This criterion is linked to a Learning Outcome Provide at least three evidence-based, peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care. 10 to >8.0 pts Excellent The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.

8 to >7.0 pts Good The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.

7 to >6.0 pts Fair Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.

6 to >0 pts Poor Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.

 10 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 to >4.0 pts Excellent Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.5 pts Good Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3.5 to >3.0 pts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.

3 to >0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion were provided.

 5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.5 pts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3.5 to >3.0 pts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors.

3 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

 5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 to >4.0 pts Excellent Uses correct APA format with no errors.

4 to >3.5 pts Good Contains a few (1 or 2) APA format errors.

3.5 to >3.0 pts Fair Contains several (3 or 4) APA format errors.

3 to >0 pts Poor Contains many (≥ 5) APA format errors.

 5 pts

Total Points: 100

 



		


		
		
		
		
	


	
		
			


	


	



	

		

			
			
				
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