Assignment 2: For AGPCNP Students Episodic Visit: Common Gynecologic Health Conditions 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.
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 SAFE ASSIGN.
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.
To prepare:
Assignment:
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Name: PRAC_6552_Week7_Assignment2_Rubric
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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-Excellent
9 (9%) – 10 (10%)
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.
Good
8 (8%) – 8 (8%)
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.
Fair
7 (7%) – 7 (7%)
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.
Poor
0 (0%) – 6 (6%)
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.
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-Excellent
9 (9%) – 10 (10%)
The response thoroughly and accurately documents the patient’s physical exam for
pertinent systems. Diagnostic tests and their results are thoroughly and accurately
documented.
Good
8 (8%) – 8 (8%)
The response accurately documents the patient’s physical exam for pertinent
systems. Diagnostic tests and their results are accurately documented.
Fair
7 (7%) – 7 (7%)
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.
Poor
0 (0%) – 6 (6%)
The response provides incomplete or inaccurate documentation of the patient’s
physical exam. Systems may have been unnecessarily reviewed, or, objective
documentation is missing.
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.-Excellent
23 (23%) – 25 (25%)
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.
Good
20 (20%) – 22 (22%)
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.
Fair
18 (18%) – 19 (19%)
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.
Poor
0 (0%) – 17 (17%)
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.
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.-Excellent
27 (27%) – 30 (30%)
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.
Good
24 (24%) – 26 (26%)
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.
Fair
21 (21%) – 23 (23%)
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.
Poor
0 (0%) – 20 (20%)
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.
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.-Excellent
9 (9%) – 10 (10%)
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.
Good
8 (8%) – 8 (8%)
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.
Fair
7 (7%) – 7 (7%)
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.
Poor
0 (0%) – 6 (6%)
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.
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.-Excellent
5 (5%) – 5 (5%)
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.
Good
4 (4%) – 4 (4%)
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.
Fair
3.5 (3.5%) – 3.5 (3.5%)
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.
Poor
0 (0%) – 3 (3%)
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.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation-Excellent
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Good
4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
Fair
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Poor
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 heads, parenthetical/in-text citations, and reference list.-Excellent
5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Good
4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
Fair
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) APA format errors.
Poor
0 (0%) – 3 (3%)
Contains many (≥ 5) APA format errors.
Total Points: 100
Name: PRAC_6552_Week7_Assignment2_Rubric