FOCUSED NOTE FOR FNP STUDENTS OB EPISODIC VISIT: 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 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.
LEARNING RESOURCES
Required Readings
• Weston, C., Page, R., Jones-Schubart, K., & Akinlotan, M. (2018). Improving cancer screening for underserved women through an FNP student-led clinicLinks to an external site.. The Journal for Nurse Practitioners, 14(5), e101–e104. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.nurpra.2018.01.013
Practicum Resources
• Walden University Field Experience. (n.d.-a).Field experience: College of Nursing.Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/home
• Walden University Field Experience. (n.d.-b). MSN nurse practitioner practicum manual.Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
• Walden University Field Experience. (n.d.-c). Student practicum resources: NP student orientation.Links to an external site. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
• HSoft Corporation. (n.d.). MeditrekLinks 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.
• Document: Focused SOAP Note Template (Word document)Download Focused SOAP Note Template (Word document)
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.).
• American Cancer Society.Links to an external site. (n.d.). https://www.cancer.org/
• American College of Obstetricians and Gynecologists.Links to an external site. (n.d.). https://www.acog.org/
• Centers for Disease Control and Prevention.Links to an external site. (n.d.). https://www.cdc.gov/ Links to an external site.
• ANA Enterprise.Links to an external site. (n.d.). https://www.nursingworld.org/
• HealthyPeople 2030. (2020).Healthy People 2030 framework.Links to an external site. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/FrameworkLinks to an external site.
• The American Association of Nurse Practitioners.Links to an external site. (2020). https://www.aanp.org/
• U.S. Preventive Services Task ForceLinks to an external site.. (n.d.-a). https://www.uspreventiveservicestaskforce.org/uspstf/
• For FNP students select a OB patient that you have examined in 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. please you have to make up her personal and medical history, family, and social history.
• Below is the template to used for this assignment.
•
• 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 what the allergy is (e.g., angioedema, anaphylaxis). 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 & 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 use seat belts all the time or whether they 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 illnesses, or chronic illnesses. The reason for 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).
• 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? types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.
• ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. 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. Breast-lumps, pain, discharge?
• 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.
• NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
• MUSCULOSKELETAL: No muscle pain, 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 or cold or heat intolerance. No polyuria or polydipsia.
• GENITOURINARY: Burning on urination. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?
• ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
• 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 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:).
• Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced 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 follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not 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 in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
• References
• You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
•
• Reflection notes: What would you do differently in a similar patient evaluation?
_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate 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.
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.
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.
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.
30 pts
This criterion is linked to a Learning Outcome
Provide at least four 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.
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.
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.
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
Additional Instructions :
please I need 4 credible references within five years .This patient will be an OB patient which means either pregnant or post partum. Please adhere to the Assignment instructions and the Rubrics .please you have to make up her personal and medical history, family, and social history.