please complete the assignment template attached starting at page 8 and on. The information regarding the patient are on the pages before it and there is also a rubric attached for additional info
SOAPNote
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Temp
late
S: Subjective
Information the patient or patient representative told you
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Initials: T.J.
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Age:
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Click or tap here to enter text.
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Gender: Female
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Height
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Weight
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BP
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HR
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RR
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Temp
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SPO2
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Pain Rating
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Allergies (and reaction)
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| 170cm |
90kg |
142/80 |
86 |
19 |
101.1F |
99% |
7/10
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Medication: Penicillin (rash/hives)
Food:
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N/A
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Environment: Cats (itchy, eye redness, watery eyes)
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History of Present Illness (HPI)
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Chief Complaint (CC)
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Infected
| Right foot pain |
CC 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”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom
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O
nset
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| 1 week |
ago
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L
ocation
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Ball of Right foot but also feels some pain in whole foot |
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D
uration
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1 week ago. Pain worse 2 days ago, current pain level 7/10 |
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C
haracteristics
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Sharp and throbbing |
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A
ggravating Factors
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Walking and weight bearing |
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R
elieving Factors
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| Tramadol |
and no weight bearing
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T
reatment
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Taking pain medication, irrigate the wound, and apply a dry dressing |
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Current Medications:
Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
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Medication
(Rx, OTC, or Homeopathic)
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Dosage
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Frequency
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Length of Time Used
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Reason for Use
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Tramadol
| 50mg PO |
| PRN |
1 week Right foot pain
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Neosporin
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N/A PRN 1 week
Right foot laceration |
| Proventil |
90mcg/spray |
Q4H PRN 2-3 puffs |
25 years |
asthma |
Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.
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Past Medical History (PMHx) –
Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
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Diabetes, Asthma diagnosed at a young age, hypertension, tetanus shot (last year), up to date with immunizations, heavy menstrual periods, ER admit last week
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Social History (Soc Hx) –
Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
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Drugs: History of marijuana use. Stopped at age 20 or 21 due to asthma exacerbation
Drinking: Socially drinks once or twice a week
Smoking/Tobacco use: No
Occupation: College student
Family status: Lives with mother and younger sister
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Family History (Fam Hx) –
Includes but not limited to 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.
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Father: Deceased due to a car accident, hypertension, type 2 diabetes, high cholesterol
Mother: hypertension, high cholesterol
Sister: asthma
Brother: N/A
Paternal grandfather: hypertension, high cholesterol, diabetes, colon cancer
Paternal grandmother: hypertension, high cholesterol
Maternal grandfather: hypertension, high cholesterol, deceased due to a heart attack
Maternal grandmother: hypertension, high cholesterol, deceased due to stroke
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Review of Systems (ROS):
Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.
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Constitutional
If patient denies all symptoms for this system, check here: ☐
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Skin
If patient denies all symptoms for this system, check here: ☐
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HEENT
If patient denies all symptoms for this system, check here: ☐
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☒Fatigue Click or tap here to enter text.
☐Weakness Click or tap here to enter text.
☒Fever/Chills Click or tap here to enter text.
☐Weight Gain
☒Weight Loss 10-lb weight loss
☒Trouble Sleeping Click or tap here to enter text.
☒Night Sweats Click or tap here to enter text.
☒Other:
Wakes up with hot flashes
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☐Itching Click or tap here to enter text.
☐Rashes Click or tap here to enter text.
☐Nail Changes Click or tap here to enter text.
☒Skin Color Changes states skin around neck is getting darker
☐Other:
Click or tap here to enter text.
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☐Diplopia Click or tap here to enter text.
☐Eye Pain Click or tap here to enter text.
☐Eye redness Click or tap here to enter text.
☒Vision changes Click or tap here to enter text.
☐Photophobia Click or tap here to enter text.
☐Eye discharge Click or tap here to enter text.
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☐Earache Click or tap here to enter text.
☐Tinnitus Click or tap here to enter text.
☐Epistaxis Click or tap here to enter text.
☐Vertigo Click or tap here to enter text.
☐Hearing Changes Click or tap here to enter text.
☐Hoarseness Click or tap here to enter text.
☐Oral Ulcers Click or tap here to enter text.
☐Sore Throat Click or tap here to enter text.
☐Congestion Click or tap here to enter text.
☐Rhinorrhea Click or tap here to enter text.
☐Other:
Click or tap here to enter text.
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Respiratory
If patient denies all symptoms for this system, check here: ☐
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Neuro
If patient denies all symptoms for this system, check here: ☒
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Cardiac and Peripheral Vascular
If patient denies all symptoms for this system, check here: ☐
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☐Cough Click or tap here to enter text.
☐Hemoptysis Click or tap here to enter text.
☐Dyspnea Click or tap here to enter text.
☒Wheezing asthma symptoms
☐Pain on Inspiration Click or tap here to enter text.
☐Sputum Production
Choose an item.
Choose an item.
Choose an item.
☐Other: Click or tap here to enter text.
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☐Syncope or Lightheadedness Click or tap here to enter text.
☐Headache Click or tap here to enter text.
☐Numbness Click or tap here to enter text.
☐Tingling Click or tap here to enter text.
☐Sensation Changes
Choose an item.
☐Speech Deficits Click or tap here to enter text.
☐Other: Click or tap here to enter text.
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☐Chest pain Click or tap here to enter text.
☒SOB due to asthma
☒Exercise Intolerance due to asthma
☐Orthopnea Click or tap here to enter text.
☐Edema Click or tap here to enter text.
☐Murmurs Click or tap here to enter text.
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☐Palpitations Click or tap here to enter text.
☐Faintness Click or tap here to enter text.
☐Claudications Click or tap here to enter text.
☐PND Click or tap here to enter text.
☐Other: Click or tap here to enter text.
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MSK
If patient denies all symptoms for this system, check here: ☐
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GI
If patient denies all symptoms for this system, check here: ☐
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GU
If patient denies all symptoms for this system, check here: ☐
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PSYCH
If patient denies all symptoms for this system, check here: ☐
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☒Pain (right foot)
☐Stiffness Click or tap here to enter text.
☐Crepitus Click or tap here to enter text.
☒Swelling (right foot)
☐Limited ROM Choose an item.
☒Redness (Right foot)
☐Misalignment Click or tap here to enter text.
☐Other: Click or tap here to enter text.
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☐Nausea/Vomiting Click or tap here to enter text.
☐Dysphasia Click or tap here to enter text.
☐Diarrhea Click or tap here to enter text.
☒Appetite Change (hungrier than usual)
☐Heartburn Click or tap here to enter text.
☐Blood in Stool Click or tap here to enter text.
☐Abdominal Pain Click or tap here to enter text.
☐Excessive Flatus Click or tap here to enter text.
☐Food Intolerance Click or tap here to enter text.
☐Rectal Bleeding Click or tap here to enter text.
☐Other:
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☐Urgency Click or tap here to enter text.
☐Dysuria Click or tap here to enter text.
☐Burning Click or tap here to enter text.
☐Hematuria Click or tap here to enter text.
☒Polyuria Click or tap here to enter text.
☒Nocturia Click or tap here to enter text.
☐Incontinence Click or tap here to enter text.
☐Other: Click or tap here to enter text.
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☒Stress (school and work related)
☒Anxiety (when father passed away)
☐Depression Click or tap here to enter text.
☐Suicidal/Homicidal Ideation Click or tap here to enter text.
☐Memory Deficits Click or tap here to enter text.
☐Mood Changes Click or tap here to enter text.
☐Trouble Concentrating Click or tap here to enter text.
☐Other: Click or tap here to enter text.
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GYN
If patient denies all symptoms for this system, check here: ☐
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Hematology/Lymphatics
If patient denies all symptoms for this system, check here: ☒
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Endocrine
If patient denies all symptoms for this system, check here: ☐
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☐Rash Click or tap here to enter text.
☐Discharge Click or tap here to enter text.
☐Itching Click or tap here to enter text.
☒Irregular Menses (6 periods a year)
☐Dysmenorrhea Click or tap here to enter text.
☐Foul Odor Click or tap here to enter text.
☐Amenorrhea Click or tap here to enter text.
☐LMP: Click or tap here to enter text.
☐Contraception Click or tap here to enter text.
☐Other:Click or tap here to enter text.
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☐Anemia Click or tap here to enter text.
☐ Easy bruising/bleeding Click or tap here to enter text.
☐ Past Transfusions Click or tap here to enter text.
☐ Enlarged/Tender lymph node(s) Click or tap here to enter text.
☐ Blood or lymph disorder Click or tap here to enter text.
☐ Other Click or tap here to enter text.
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☐ Abnormal growth Click or tap here to enter text.
☒ Increased appetite Click or tap here to enter text.
☒ Increased thirst Click or tap here to enter text.
☐ Thyroid disorder Click or tap here to enter text.
☐ Heat/cold intolerance Click or tap here to enter text.
☐ Excessive sweating Click or tap here to enter text.
☒ Diabetes Click or tap here to enter text.
☐ Other Click or tap here to enter text.
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O: Objective
Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Pertinent positive are the “abnormal” findings and pertinent “negative” are the expected normal findings. Separate the assessment findings accordingly and be detailed.
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Body System
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Positive Findings
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Negative Findings
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General
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N/A
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N/A
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Skin
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Wound found on the ball of right foot. Redness, swelling, and warm to touch around the area. White color drainage at the site of injury. Wound measurement: 2cm x 1.5 cm, 2.5 mm deep
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No odor noted
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HEENT
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N/A
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N/A
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Respiratory
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Neuro
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Cardiovascular
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Musculoskeletal
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Gastrointestinal
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Genitourinary
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Psychiatric
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Gynecological
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Problem List
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| Acute pain on Right foot |
6. Obesity
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11. Click or tap here to enter text.
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2. Asthma
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7. Oligomenorrhea
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12. Click or tap here to enter text.
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3. Uncontrolled diabetes
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8. Menorrhagia
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13. Click or tap here to enter text.
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4. .
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9. Headaches
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14. Click or tap here to enter text.
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5. Obesity
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10. Click or tap here to enter text.
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15. Click or tap here to enter text.
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A: Assessment
Medical Diagnoses. Provide 3 differential diagnoses (DDx) which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.
Diagnosis
ICD-10 Code
Pertinent Findings
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P: Plan
Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.
Diagnostics:
List tests you will order this visit
Test
Rationale/Citation
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Medications:
List medications/treatments including OTC drugs you will order and “continue meds” if pertinent.
Drug
Dosage
Length of Treatment
Rationale/Citation
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Referral/Consults:
Click or tap here to enter text.
Rationale/Citation
Click or tap here to enter text.
Education:
Click or tap here to enter text.
Rationale/Citation
Click or tap here to enter text.
Follow Up:
Indicate when patient should return to clinic and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere.
Click or tap here to enter text.
Rationale/Citation
Click or tap here to enter text.
References
Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting.
Click or tap here to enter text.
Introduction and Pre-brief
In this graded assignment, you will interview Tina Jones to conduct a comprehensive health history and collect data to assess Ms. Jones’ recent right foot injury. You will have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem list using evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; and plan how to best address the most important concern with further assessment, interventions, and patient education. For this assignment, you will conduct a limited physical assessment. Your objective documentation must include a general statement and the findings for the skin (integumentary) body system.
Purposes
The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the individual needs of the patient, (d) apply assessment skills and techniques to gather subjective and objective data, (e) differentiate normal from abnormal physical examination findings, (f) summarize, organize, and appropriately document findings using correct professional terminology, (g) practice developing primary and differential diagnoses, (h) practice creating treatment plans which include diagnostics, medication, education, consultation/referral, and follow-up planning; and (i) analyze and reflect on own performance to gain insight and foster knowledge.
Activity Learning Outcomes
Through this assignment, the student will demonstrate the ability to:
1. Apply knowledge and understanding of advanced practice physical assessment skills and techniques (CO1)
2. Perform focused and comprehensive histories and physical assessments for various patient populations (CO4 and CO5)
3. Adapt skills and techniques to suit the individual needs of the patient (CO4)
4. Differentiate normal from abnormal physical examination findings (CO2)
5. Summarize, organize, and document findings using correct professional terminology (CO3)
6. Reflect upon performance to gain insight and foster knowledge (CO1)
Requirements
NOTE: Before initiating any activity in Shadow Health, complete the required course weekly readings and lessons as well as review the introduction and pre-brief
On the Canvas Platform:
1. Summarize, organize, and appropriately document findings using correct professional terminology on the SOAP Note Template.
2. Document a comprehensive problem list based upon the history and physical examination findings on the SOAP Note Template.
3. Provide rationales and citations for diagnoses and interventions for the brief treatment plan.
4. Include at least one scholarly source to support diagnoses and treatment interventions with rationales and references on the SOAP note. Only scholarly sources are acceptable for citation and reference in this course. These include peer-reviewed publications, government reports, or sources written by a professional or scholar in the field. The textbooks and lessons are NOT considered to be outside scholarly sources. For the threaded discussions and reflection posts, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org) can be counted as scholarly sources. The best outside scholarly source to use is a peer-reviewed nursing journal. The following sources should not be used: Wikipedia, Wikis, or blogs. These websites are not considered scholarly as anyone can add to these. Please be aware that .com websites can vary in scholarship and quality. For example, the American Heart Association is a .com site with scholarship and quality. Each student is responsible for determining the scholarship and quality of any .com site. Ask your instructor before using any site if you are unsure. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Current outside scholarly sources must be published with the last 5 years.
Shadow Health Grading
Rubric
Portions of the rubric are designated with a ***. The following explains those portions of the rubric:
**Scholarly Sources: Only scholarly sources are acceptable for citation and reference in this course. These include peer-reviewed publications, government reports, or sources written by a professional or scholar in the field. The textbooks and lessons are NOTconsidered to be outside scholarly sources. For the threaded discussions and reflection posts, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org) can be counted as scholarly sources. The best outside scholarly source to use is a peer-reviewed nursing journal. You are encouraged to use the Chamberlain library and search one of the available databases for a peer-reviewed journal article. The following sources should not be used: Wikipedia, Wikis, or blogs. These websites are not considered scholarly as anyone can add to these. Please be aware that .com websites can vary in scholarship and quality. For example, the American Heart Association is a .com site with scholarship and quality. Each student is responsible for determining the scholarship and quality of any .com site. Ask your instructor before using any site if you are unsure. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Current outside scholarly sources must be published with the last 5 years. Instructor permission must be obtained BEFORE the assignment is due if using a source that is older than 5 years.
***Components of a treatment plan include diagnostics, medication, education, consultation/referral, and follow-up planning
****Insight refers to the capacity to gain an accurate and deep intuitive understanding of a concept or thing. For example, one might demonstrate insight by relating a concept to a personal or meaningful experience.
ASSIGNMENT CONTENT
Category
Description
Assessment, Documentation, Treatment Plan, and Scholarly Sources
This category is evaluated on the quality of student’s ability to: Identify pertinent normal and abnormal findings for the assignment, utilize professional terminology, provide comprehensive and detailed subjective and objective documentation, and identify relevant problems on the problem list. Include at least one appropriate EBP scholarly source with the SOAP note.
Total CONTENT Points= 65
ASSIGNMENT FORMAT
Category
Description
Grammar, Spelling, Syntax, Mechanics and APA Format
Reflection post has minimal grammar, spelling, syntax, punctuation and APA* errors. Direct quotes (if used) is limited to 1 short statement** which adds substantively to the post.
* APA style references and in text citations are required; however, there are no deductions for errors in indentation or spacing of references. All elements of the reference otherwise must be included.
**Direct quote should not to exceed 15 words & must add substantively to the assignment
Total FORMAT Points= 10
ASSIGNMENT TOTAL= 75 points
Rubric
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Criteria
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Ratings
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Pts
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This criterion is linked to a Learning OutcomeCriterion 2 Assessment, Documentation, Treatment Plan, and Scholarly Sources
Criterion 2
Assessment, Documentation, Treatment Plan, and Scholarly Sources
Must demonstrate the following elements:
Identify all pertinent normal and abnormal findings;
Use professional terminology;
Subjective and objective documentation was detailed and comprehensive;
Use the SOAP Note Format template for documentation;
Address each of the following on the brief treatment plan: Diagnostics, Medication, Education, Referral/Consultation, and Follow-up Planning;
Interventions are detailed and appropriate for the focused assignment;
Provide at least one appropriate EBP scholar source
(7 Required Elements)
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35 pts
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Excellent
Identifies 12 out of 12 diagnoses on the problem list AND Demonstrates all elements for the Criterion
32 pts
V. Good
Identifies 10-12 out of 12 diagnoses on the problem list OR Missing 1-2 elements for the Criterion
29 pts
Satisfactory
Identifies 8-9 out of twelve diagnoses on the problem list OR Missing 3-4 elements for the Criterion
18 pts
Needs Improvement
Identifies 6-7 diagnoses on the problem list OR Missing 5 elements on for the Criterion
0 pts
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Unsatisfactory
Identifies 5 or fewer diagnoses on the problem list OR Missing 6 or more elements for the Criterion OR No Assignment
35 pts
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This criterion is linked to a Learning OutcomeAssignment Format Possible Points = 10 Points
Format Criterion 1
Grammar, Spelling, Syntax, Mechanics and APA Format
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10 pts
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Excellent
0-1 errors in grammar, syntax, spelling, punctuation, mechanics, or APA format
9 pts
V. Good
2-3 errors in grammar, syntax, spelling, punctuation, mechanics, or APA format
8 pts
Satisfactory
4-5 errors in grammar, syntax, spelling, punctuation, mechanics, or APA format
5 pts
Needs Improvement
6-7 errors in grammar, syntax, spelling, punctuation, mechanics, or APA format
0 pts
Unsatisfactory
8 or more errors in grammar, syntax, spelling, punctuation, mechanics, or APA format OR No assignment
10 pts
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This criterion is linked to a Learning OutcomeLate Penalty Deductions
Students are expected to submit assignments by the time they are due. Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment. Quizzes and discussions are not considered assignments and are not part of the late assignment policy.
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0 pts
Minus Points
0 pts
Minus Points
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0 pts
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Total Points: 75
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