a 4–5 page patient-centered needs assessment to demonstrate how to leverage health care technology to improve patient engagement and outcomes for a specific patient population. This could focus on a disease or a disorder based on the best available evidence that has been individualized to treat your patient’s health, economic, and cultural needs.
The bullet points below correspond to the grading criteria in the rubric. . If you are having a difficult time choosing a topic, review the Healthy People 2030 topics and try to find a topic that is interesting and relevant to you.
- the importance of addressing patient engagement in the management of a patient’s specific health, economic, and cultural needs based on the best available evidence.
- Why is patient engagement necessary to ensure that patients are better able to manage their specific health conditions?
- What evidence in the current literature (published within the last fiveyears) supports the benefit of patient engagement?
- the potential use and impact of information and communication technology tools needed to improve consumer health literacy for a specific patient population.
- Consider what type of health care technology modalities are useful to improve consumer health literacy
- Are there mobile applications, telehealth features, or other technology that can facilitate improving patient care?
- the value and relevance of the technology modalities that may be used to address the needs identified in the patient population assessment.
- How does each proposed technology modality encourage patient engagement in an ethical, culturally sensitive, and inclusive way?
- Ensure that your strategies:
- Promote honest communications.
- Facilitate sharing only the information you are required and permitted to share.
- Enable you to make complex medical terms and concepts understandable to your patient and their family regardless of language, abilities, or educational level.
- Consider how health information exchange and interoperability of technology modalities contribute to their value.
- innovative strategies for leveraging technology to support quality, ethical, and efficient patient care that is culturally and linguistically appropriate for the identified patient population.
- Consider how the selected technology impacts the patient in the most efficient way.
- Is the selected technology culturally and linguistically appropriate?
- how the proposed strategies will mitigate the risk of adverse outcomes due to inequity in access to patient personal health data and technology modalities.
- What are potential risks that could lead to adverse outcomes for certain members of the population?
- How will those risks be mitigated?
- How have your proposed strategies been used previously to address iniquities and risks?
NEEDS ASSESSMENT 1
Evidence-Based Patient-Centered Needs Assessment
Student’s Name
Course
Instructor
Date
NEEDS ASSESSMENT 2
Evidence-Based Patient-Centered Needs Assessment
Introduction
Evidence-based practice is crucial in contemporary healthcare to guarantee high-quality
treatment and improve patient outcomes. In order to enhance patient outcomes and engagement
for a particular patient group, this article will offer an evidence-based patient-centered needs
assessment. People with type 2 diabetes, a chronic illness needing active patient engagement in
its care, are the target patient group. In addition to discussing technology-leverage tactics and
possible concerns related to unequal access to healthcare technology, this article will examine the
value of patient participation and assess the effects of ICT tools.
Importance of Addressing Patient Engagement
Effective healthcare delivery, which acknowledges individuals as active partners in their
health management, is built on patient engagement. By including patients in decision-making,
supporting improved adherence to treatment approaches, and encouraging healthier lives, patient
engagement allows people to take charge of their health (Brand-McCarthy et al., 2020). Patient
involvement, for instance, might result in more individualized food and activity advice for the
treatment of type 2 diabetes that takes into consideration cultural preferences and financial
limitations.
Patient participation is essential because it promotes informed decision-making since
involved patients have a deeper understanding of their diseases and available treatments (Brand-
McCarthy et al., 2020). With this information, they are more equipped to collaborate with
healthcare providers to make educated decisions, which is essential for chronic illnesses like
diabetes, where self-management choices significantly impact health outcomes. Additionally,
increased treatment adherence results from patient involvement (Chen et al., 2020). Patients who
NEEDS ASSESSMENT 3
take an active role in their care are more likely to take their medicines and treatments as directed,
improving their health outcomes. Additionally, patient involvement promotes increased health
knowledge. Patients can better understand medical information, participate in shared decision-
making, and recognize possible problems when they have the knowledge and abilities to manage
their diseases efficiently (Whitehouse et al., 2020). Therefore, increased patient participation
results in better patient outcomes.
Potential Use and Impact of Information and Communication Technology Tools
The integration of diverse modalities intended to empower patients and improve their
involvement in their treatment has been made possible by advancements in healthcare
technology. Mobile apps are one of these methods; they are flexible tools that have the power to
change patient engagement completely. These applications include monitoring capabilities for
blood glucose readings, food recording, and activity tracking for people with diabetes (Healthy
People 2030, 2023). The user-friendly interfaces and adaptable features of well-known examples
like MyFitnessPal and Glucose Buddy enable patients to customize the apps to their
requirements.
Along with mobile apps, telehealth features have become a game-changing means of
promoting patient participation. They remove geographic constraints that can obstruct access to
care by enabling patients to contact healthcare professionals remotely (Noel et al., 2020).
Additionally, the messaging capabilities of telehealth encourage constant communication
between patients and physicians, ensuring that issues are resolved quickly and successfully.
Another significant development in healthcare technology is wearables. By offering
continuous health monitoring, gadgets like smartwatches and fitness trackers go beyond
conventional data-collecting techniques (Iqbal et al., 2020). Thanks to this real-time data
NEEDS ASSESSMENT 4
gathering, patients may have quick access to information about their health indicators, which can
be particularly helpful for those treating diabetes.
Finally, patient portals provide quick access to medical information through safe internet
platforms. Access to medical data, test results, and educational materials are just a few
advantages these portals provide (Benjamins et al., 2021). Patient portals are especially
important for those with long-term diseases like diabetes since they may help them manage their
conditions better and get better results by keeping them informed.
Value and Relevance of the Technology Modalities
Mobile apps, telemedicine capabilities, and patient portals are just a few examples of the
technology modalities crucial for fostering patient interaction while respecting moral standards,
cultural sensitivity, and inclusion. Ethical and culturally aware engagement ensures meaningful
patient connection with these technologies. By providing food advice and exercise regimens that
are culturally appropriate, mobile apps aid in patient involvement (Healthy People 2030, 2023).
These applications respect ethical norms by offering open data use rules and letting users manage
data sharing. Healthcare professionals may better grasp patients' comprehension levels by
communicating treatment alternatives through telehealth (Noel et al., 2020). Patient portals also
play a significant part in encouraging ethical involvement by allowing patients access to their
medical information and fostering more openness throughout their treatment journey.
Maintaining patient confidence in technology-driven healthcare depends heavily on
encouraging open communication and information exchange. Mobile apps maintain this by
providing accurate health information from reliable sources and adhering to evidence-based
recommendations. They support informed decision-making and adherence to suggested methods
by boosting patient trust in the information they receive (Brand-McCarthy et al., 2020).
NEEDS ASSESSMENT 5
Furthermore, telemedicine consultations sustain patient-provider trust by exchanging pertinent
medical information and discussing treatment choices.
Creating an extensive patient profile increases the interchange across technological
modalities' value. Patient portals are enriched with up-to-date information thanks to data
effortlessly incorporated from mobile applications, wearable technology, and telehealth
engagements. These data enable tailored treatment plans that enhance patient outcomes by
allowing healthcare professionals to make well-informed choices based on the most recent data.
Strategies for Leveraging Technology
Technology-enabled patient care for those with type 2 diabetes demands creative
approaches that consider cultural and language considerations. It is crucial to use culturally and
linguistically sensitive tactics to make sure that patient care is supported by healthcare
technology effectively. Technology tools may close the gap between healthcare
recommendations and cultural traditions by providing individualized health advice that aligns
with patients' cultural norms and dietary choices (Whitehouse et al., 2020). For instance, a
mobile app created to help people with type 2 diabetes may provide culturally appropriate
recipes for the patient. This approach supports dietary modifications that are health-conscious
and culturally appropriate while also respecting cultural customs, which promotes patient
participation.
In order to improve patient involvement, multilingual interfaces must be included in
technological solutions. Patients who speak languages other than English can obtain information
and interact successfully in a diversified healthcare environment (Bhawra et al., 2022). The
NEEDS ASSESSMENT 6
patient-centered approach may be strengthened by including language choices in mobile
applications and patient portals, enabling patients to understand and take an active role in their
treatment. To efficiently break down medical information so patients understand their diseases
and treatment plans better, the applications and portals may include simple language
explanations, visual aids, and interactive modules.
Wearable technology allows for remote monitoring, which is a huge breakthrough in
terms of technology's efficiency. With wearable technology, patients may monitor vital statistics,
including blood glucose levels and physical activity, in real-time (Iqbal et al., 2021). Healthcare
professionals may easily access this data, allowing them to see patterns and take quick action.
This preemptive strategy lowers the likelihood of issues and hospital stays, eventually improving
patient outcomes.
The technical modalities also demonstrate a dedication to cultural diversity. For instance,
culturally appropriate information, such as nutrition advice and instructional materials, should
reflect patients' cultural origins and preferences (Buchanan et al., 2020). Also important is
language accessibility. In order to recognize and accommodate linguistic variety, mobile
applications, telehealth platforms, and patient portals provide user interfaces and resources in
many languages. This accessibility ensures that patients may access critical information without
encountering language obstacles.
Mitigating Risks of Inequity in Access
When certain populations lack access to key technologies like smartphones and
dependable internet connections, the digital gap is the first possible risk that might harm the
outcomes for type 2 diabetes patients (Whitehouse et al., 2020). This digital gap may result in
uneven access to patient portals, telehealth services, and health applications. Patient involvement
NEEDS ASSESSMENT 7
and comprehension may suffer if they require assistance navigating complicated technological
interfaces, which is another concern. Their capacity to actively take part in their treatment and
make informed choices may be hampered by this danger.
However, there are several strategies to reduce these dangers for patients, such as
working with community groups that can close the digital divide by giving underprivileged
communities access to technological resources (Bhawra et al., 2022). Community centers may
provide access to technology and help utilize patient portals and health applications.
Additionally, it is essential to provide user-friendly technology interfaces with straightforward
navigation and explanations in everyday language that can accommodate patients with different
levels of health literacy.
Mitigation measures have been used in various healthcare situations to address risks and
disparities. Community collaborations, for instance, have been utilized to reduce inequities in
distant communities' access to healthcare. Partnerships with neighborhood groups and mobile
health clinics efficiently reduce care delivery gaps. Additionally, accessible technology interfaces
have been developed for various demographics using user-centered design principles (Bhawra et
al., 2022). Furthermore, telehealth outreach was carried out through phone calls To contact
susceptible communities during the COVID-19 pandemic (Dejong et al., 2020). These
conversations guarantee that despite access to technological restrictions, patients get medical
care and counseling.
Conclusion
In conclusion, this article emphasizes the significance of using healthcare technology for
enhanced patient engagement and results, particularly for people with type 2 diabetes. The
solutions described strongly emphasize moral, linguistic, and cultural factors, understanding that
NEEDS ASSESSMENT 8
effective implementation depends on patient empowerment and fair access. Healthcare providers
may influence positive improvements in patient self-management, treatment adherence, and
general well-being by encouraging patient participation using cutting-edge technology,
addressing cultural diversity, boosting health literacy, and reducing possible dangers. Technology
facilitates patient-centered care that overcomes obstacles, improves communication, and alters
healthcare experiences via these all-encompassing activities.
References
Benjamins, J., Haveman-Nies, A., Gunnink, M., Goudkuil, A., & De Vet, E. (2021). How
the use of a patient-accessible health record contributes to patient-centered care: a
scoping review. Journal of medical Internet research, 23(1), e17655.
NEEDS ASSESSMENT 9
Bhawra, J., Buchan, M. C., Green, B., Skinner, K., & Katapally, T. R. (2022). A guiding
framework for needs assessment evaluations to embed digital platforms in partnership
with Indigenous communities. PLoS One, 17(12), e0279282.
Brand-McCarthy, S. R., Delaney, R. K., Noseworthy, P. A., & STEP-UP AFIB Writing
Group. (2020). Can shared decision-making improve stroke prevention in atrial
fibrillation? implications of the updated guidelines. Circulation: Cardiovascular Quality
and Outcomes, 13(3), e006080.
Buchanan, C., Howitt, M. L., Wilson, R., Booth, R. G., Risling, T., & Bamford, M.
(2020). Nursing in the age of artificial intelligence: Protocol for a scoping review. JMIR
research protocols, 9(4), e17490.
Chen, S. C. I., Hu, R., & McAdam, R. (2020). Smart, remote, and targeted health care
facilitation through connected health: Qualitative study. Journal of medical Internet
research, 22(4), e14201.
DeJong, C., Chen, A. H., & Lo, B. (2020). An ethical framework for allocating scarce
inpatient medications for COVID-19 in the US. JAMA, 323(23), 2367-2368.
Healthy People 2030. (2023, April 27). Diabetes management: Mobile phone
applications used within healthcare systems for type 2 diabetes self-management7. The
Community Guide. https://www.thecommunityguide.org/findings/diabetes-management-
mobile-phone-applications-used-within-healthcare-systems-type-2.html
Iqbal, S. M., Mahgoub, I., Du, E., Leavitt, M. A., & Asghar, W. (2021). Advances in
healthcare wearable devices. NPJ Flexible Electronics, 5(1), 9.
NEEDS ASSESSMENT 10
Noel, K., Messina, C., Hou, W., Schoenfeld, E., & Kelly, G. (2020). Tele-transitions of
care (TTOC): a 12-month, randomized controlled trial evaluating the use of telehealth to
achieve triple aim objectives. BMC family practice, 21, 1-9.
Whitehouse, C. R., Long, J. A., Maloney, L. M., Daniels, K., Horowitz, D. A., & Bowles,
K. H. (2020). Feasibility of diabetes self-management telehealth education for older
adults during transitions in care. Research in gerontological nursing, 13(3), 138-145.
,
NEEDS ASSESSMENT 1
Evidence-Based Patient-Centered Needs Assessment
Student’s Name
Course
Instructor
Date
NEEDS ASSESSMENT 2
Evidence-Based Patient-Centered Needs Assessment
Introduction
Evidence-based practice is crucial in contemporary healthcare to guarantee high-quality
treatment and improve patient outcomes. In order to enhance patient outcomes and engagement
for a particular patient group, this article will offer an evidence-based patient-centered needs
assessment. People with type 2 diabetes, a chronic illness needing active patient engagement in
its care, are the target patient group. In addition to discussing technology-leverage tactics and
possible concerns related to unequal access to healthcare technology, this article will examine the
value of patient participation and assess the effects of ICT tools.
Importance of Addressing Patient Engagement
Effective healthcare delivery, which acknowledges individuals as active partners in their
health management, is built on patient engagement. By including patients in decision-making,
supporting improved adherence to treatment approaches, and encouraging healthier lives, patient
engagement allows people to take charge of their health (Brand-McCarthy et al., 2020). Patient
involvement, for instance, might result in more individualized food and activity advice for the
treatment of type 2 diabetes that takes into consideration cultural preferences and financial
limitations.
Patient participation is essential because it promotes informed decision-making since
involved patients have a deeper understanding of their diseases and available treatments (Brand-
McCarthy et al., 2020). With this information, they are more equipped to collaborate with
healthcare providers to make educated decisions, which is essential for chronic illnesses like
diabetes, where self-management choices significantly impact health outcomes. Additionally,
increased treatment adherence results from patient involvement (Chen et al., 2020). Patients who
NEEDS ASSESSMENT 3
take an active role in their care are more likely to take their medicines and treatments as directed,
improving their health outcomes. Additionally, patient involvement promotes increased health
knowledge. Patients can better understand medical information, participate in shared decision-
making, and recognize possible problems when they have the knowledge and abilities to manage
their diseases efficiently (Whitehouse et al., 2020). Therefore, increased patient participation
results in better patient outcomes.
Potential Use and Impact of Information and Communication Technology Tools
The integration of diverse modalities intended to empower patients and improve their
involvement in their treatment has been made possible by advancements in healthcare
technology. Mobile apps are one of these methods; they are flexible tools that have the power to
change patient engagement completely. These applications include monitoring capabilities for
blood glucose readings, food recording, and activity tracking for people with diabetes (Healthy
People 2030, 2023). The user-friendly interfaces and adaptable features of well-known examples
like MyFitnessPal and Glucose Buddy enable patients to customize the apps to their
requirements.
Along with mobile apps, telehealth features have become a game-changing means of
promoting patient participation. They remove geographic constraints that can obstruct access to
care by enabling patients to contact healthcare professionals remotely (Noel et al., 2020).
Additionally, the messaging capabilities of telehealth encourage constant communication
between patients and physicians, ensuring that issues are resolved quickly and successfully.
Another significant development in healthcare technology is wearables. By offering
continuous health monitoring, gadgets like smartwatches and fitness trackers go beyond
conventional data-collecting techniques (Iqbal et al., 2020). Thanks to this real-time data
NEEDS ASSESSMENT 4
gathering, patients may have quick access to information about their health indicators, which can
be particularly helpful for those treating diabetes.
Finally, patient portals provide quick access to medical information through safe internet
platforms. Access to medical data, test results, and educational materials are just a few
advantages these portals provide (Benjamins et al., 2021). Patient portals are especially
important for those with long-term diseases like diabetes since they may help them manage their
conditions better and get better results by keeping them informed.
Value and Relevance of the Technology Modalities
Mobile apps, telemedicine capabilities, and patient portals are just a few examples of the
technology modalities crucial for fostering patient interaction while respecting moral standards,
cultural sensitivity, and inclusion. Ethical and culturally aware engagement ensures meaningful
patient connection with these technologies. By providing food advice and exercise regimens that
are culturally appropriate, mobile apps aid in patient involvement (Healthy People 2030, 2023).
These applications respect ethical norms by offering open data use rules and letting users manage
data sharing. Healthcare professionals may better grasp patients' comprehension levels by
communicating treatment alternatives through telehealth (Noel et al., 2020). Patient portals also
play a significant part in encouraging ethical involvement by allowing patients access to their
medical information and fostering more openness throughout their treatment journey.
Maintaining patient confidence in technology-driven healthcare depends heavily on
encouraging open communication and information exchange. Mobile apps maintain this by
providing accurate health information from reliable sources and adhering to evidence-based
recommendations. They support informed decision-making and adherence to suggested methods
by boosting patient trust in the information they receive (Brand-McCarthy et al., 2020).
NEEDS ASSESSMENT 5
Furthermore, telemedicine consultations sustain patient-provider trust by exchanging pertinent
medical information and discussing treatment choices.
Creating an extensive patient profile increases the interchange across technological
modalities' value. Patient portals are enriched with up-to-date information thanks to data
effortlessly incorporated from mobile applications, wearable technology, and telehealth
engagements. These data enable tailored treatment plans that enhance patient outcomes by
allowing healthcare professionals to make well-informed choices based on the most recent data.
Strategies for Leveraging Technology
Technology-enabled patient care for those with type 2 diabetes demands creative
approaches that consider cultural and language considerations. It is crucial to use culturally and
linguistically sensitive tactics to make sure that patient care is supported by healthcare
technology effectively. Technology tools may close the gap between healthcare
recommendations and cultural traditions by providing individualized health advice that aligns
with patients' cultural norms and dietary choices (Whitehouse et al., 2020). For instance, a
mobile app created to help people with type 2 diabetes may provide culturally appropriate
recipes for the patient. This approach supports dietary modifications that are health-conscious
and culturally appropriate while also respecting cultural customs, which promotes patient
participation.
In order to improve patient involvement, multilingual interfaces must be included in
technological solutions. Patients who speak languages other than English can obtain information
and interact successfully in a diversified healthcare environment (Bhawra et al., 2022). The
NEEDS ASSESSMENT 6
patient-centered approach may be strengthened by including language choices in mobile
applications and patient portals, enabling patients to understand and take an active role in their
treatment. To efficiently break down medical information so patients understand their diseases
and treatment plans better, the applications and portals may include simple language
explanations, visual aids, and interactive modules.
Wearable technology allows for remote monitoring, which is a huge breakthrough in
terms of technology's efficiency. With wearable technology, patients may monitor vital statistics,
including blood glucose levels and physical activity, in real-time (Iqbal et al., 2021). Healthcare
professionals may easily access this data, allowing them to see patterns and take quick action.
This preemptive strategy lowers the likelihood of issues and hospital stays, eventually improving
patient outcomes.
The technical modalities also demonstrate a dedication to cultural diversity. For instance,
culturally appropriate information, such as nutrition advice and instructional materials, should
reflect patients' cultural origins and preferences (Buchanan et al., 2020). Also important is
language accessibility. In order to recognize and accommodate linguistic variety, mobile
applications, telehealth platforms, and patient portals provide user interfaces and resources in
many languages. This accessibility ensures that patients may access critical information without
encountering language obstacles.
Mitigating Risks of Inequity in Access
When certain populations lack access to key technologies like smartphones and
dependable internet connections, the digital gap is the first possible risk that might harm the
outcomes for type 2 diabetes patients (Whitehouse et al., 2020). This digital gap may result in
uneven access to patient portals, telehealth services, and health applications. Patient involvement
NEEDS ASSESSMENT 7
and comprehension may suffer if they require assistance navigating complicated technological
interfaces, which is another concern. Their capacity to actively take part in their treatment and
make informed choices may be hampered by this danger.
However, there are several strategies to reduce these dangers for patients, such as
working with community groups that can close the digital divide by giving underprivileged
communities access to technological resources (Bhawra et al., 2022). Community centers may
provide access to technology and help utilize patient portals and health applications.
Additionally, it is essential to provide user-friendly technology interfaces with straightforward
navigation and explanations in everyday language that can accommodate patients with different
levels of health literacy.
Mitigation measures have been used in various healthcare situations to address risks and
disparities. Community collaborations, for instance, have been utilized to reduce inequities in
distant communities' access to healthcare. Partnerships with neighborhood groups and mobile
health clinics efficiently reduce care delivery gaps. Additionally, accessible technology interfaces
have been developed for various demographics using user-centered design principles (Bhawra et
al., 2022). Furthermore, telehealth outreach was carried out through phone calls To contact
susceptible communities during the COVID-19 pandemic (Dejong et al., 2020). These
conversations guarantee that despite access to technological restrictions, patients get medical
care and counseling.
Conclusion
In conclusion, this article emphasizes the significance of using healthcare technology for
enhanced patient engagement and results, particularly for people with type 2 diabetes. The
solutions described strongly emphasize moral, linguistic, and cultural factors, understanding that
NEEDS ASSESSMENT 8
effective implementation depends on patient empowerment and fair access. Healthcare providers
may influence positive improvements in patient self-management, treatment adherence, and
general well-being by encouraging patient participation using cutting-edge technology,
addressing cultural diversity, boosting health literacy, and reducing possible dangers. Technology
facilitates patient-centered care that overcomes obstacles, improves communication, and alters
healthcare experiences via these all-encompassing activities.
References
Benjamins, J., Haveman-Nies, A., Gunnink, M., Goudkuil, A., & De Vet, E. (2021). How
the use of a patient-accessible health record contributes to patient-centered care: a
scoping review. Journal of medical Internet research, 23(1), e17655.
NEEDS ASSESSMENT 9
Bhawra, J., Buchan, M. C., Green, B., Skinner, K., & Katapally, T. R. (2022). A guiding
framework for needs assessment evaluations to embed digital platforms in partnership
with Indigenous communities. PLoS One, 17(12), e0279282.
Brand-McCarthy, S. R., Delaney, R. K., Noseworthy, P. A., & STEP-UP AFIB Writing
Group. (2020). Can shared decision-making improve stroke prevention in atrial
fibrillation? implications of the updated guidelines. Circulation: Cardiovascular Quality
and Outcomes, 13(3), e006080.
Buchanan, C., Howitt, M. L., Wilson, R., Booth, R. G., Risling, T., & Bamford, M.
(2020). Nursing in the age of artificial intelligence: Protocol for a scoping review. JMIR
research protocols, 9(4), e17490.
Chen, S. C. I., Hu, R., & McAdam, R. (2020). Smart, remote, and targeted health care
facilitation through connected health: Qualitative study. Journal of medical Internet
research, 22(4), e14201.
DeJong, C., Chen, A. H., & Lo, B. (2020). An ethical framework for allocating scarce
inpatient medications for COVID-19 in the US. JAMA, 323(23), 2367-2368.
Healthy People 2030. (2023, April 27). Diabetes management: Mobile phone
applications used within healthcare systems for type 2 diabetes self-management7. The
Community Guide. https://www.thecommunityguide.org/findings/diabetes-management-
mobile-phone-applications-used-within-healthcare-systems-type-2.html
Iqbal, S. M., Mahgoub, I., Du, E., Leavitt, M. A., & Asghar, W. (2021). Advances in
healthcare wearable devices. NPJ Flexible Electronics, 5(1), 9.
NEEDS ASSESSMENT 10
Noel, K., Messina, C., Hou, W., Schoenfeld, E., & Kelly, G. (2020). Tele-transitions of
care (TTOC): a 12-month, randomized controlled trial evaluating the use of telehealth to
achieve triple aim objectives. BMC family practice, 21, 1-9.
Whitehouse, C. R., Long, J. A., Maloney, L. M., Daniels, K., Horowitz, D. A., & Bowles,
K. H. (2020). Feasibility of diabetes self-management telehealth education for older
adults during transitions in care. Research in gerontological nursing, 13(3), 138-145.
Soap Note 1 is based on the Case Study # 1 ATTACHED (10 Points)
You MUST use the Case Study #1 as the base of this SOAP NOTE #1
Must use the sample template for your soap note,(ATTACHED)
Student must use the template provided. No passing grade will be granted if this section is not completed properly.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 15% or will not be accepted for credit, must be your own work and in your own words.
The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.
3 pages
due date June 4, 2024
Grading Rubric
Student______________________________________
This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.
1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.
2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:
a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).
b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.
3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.
a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).
b) Pertinent positives and negatives must be documented for each relevant system.
c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).
4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.
5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.
6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.
7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?
Comments:
Total Score: ____________ Instructor: __________________________________
Guidelines for Focused SOAP Notes
· Label each section of the SOAP note (each body part and system).
· Do not use unnecessary words or complete sentences.
· Use Standard Abbreviations
S: SUBJECTIVE DATA (information the patient/caregiver tells you).
Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.
History of present illness (HPI): a chronological description of the development of the patient's chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.
Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.
Family History (FH): Update significant medical information about the patient's family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.
Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.
0: OBJECTIVE DATA (information you observe, assessment findings, lab results).
Sufficient physical exam should be performed to evaluate areas suggested by the history and patient's progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.
Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.
NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.
Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.
Do not write that a diagnosis is to be "ruled out" rather state the working definitions of each differential or primary diagnosis (es).
For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.
P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.
2. Additional diagnostic tests include EBP citations to support ordering additional tests
3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.
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(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
·
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
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–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
· –
· –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
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Case Study: Iron Deficiency Anemia Patient Information:
• Name: John Doe
• Age: 35
• Gender: Male
• Occupation: Construction Worker
• Medical History: No significant medical history reported. Presenting Complaint: John Doe presents to the clinic with complaints of fatigue, weakness, and shortness of breath on exertion for the past few months. He reports feeling unusually tired, even after a full night's sleep, and has noticed increased paleness of his skin and conjunctiva. Physical Examination Findings:
• Vital Signs: BP 120/80 mmHg, HR 80 bpm, RR 16 breaths/min, Temp 98.6°F
• General: Pale skin and conjunctiva, fatigue apparent
• Cardiovascular: Regular rhythm, no murmurs or abnormal sounds
• Respiratory: Clear lung fields bilaterally
• Abdomen: Soft, non-tender, no organomegaly
• Neurological: Intact cranial nerves, normal motor and sensory functions Laboratory Investigations:
• Hemoglobin (Hb): 9.5 g/dL (Normal range: 13.5-17.5 g/dL)
• Hematocrit (Hct): 29% (Normal range: 40-50%)
• Mean Corpuscular Volume (MCV): 75 fL (Normal range: 80-100 fL)
• Serum Iron: 25 mcg/dL (Normal range: 60-170 mcg/dL)
• Total Iron Binding Capacity (TIBC): 400 mcg/dL (Normal range: 250-450 mcg/dL)
• Ferritin: 10 ng/mL (Normal range: 30-400 ng/mL) Diagnosis: John Doe is diagnosed with iron deficiency anemia based on his clinical presentation, physical examination findings, and laboratory results. Questions for Students:
1. What are the common signs and symptoms of iron deficiency anemia?
2. Explain the laboratory findings in John Doe's case and how they support the diagnosis of iron deficiency anemia.
3. What are the potential causes of iron deficiency anemia in adults, and how would you approach further investigations in this patient?
4. Discuss the treatment options for iron deficiency anemia, including dietary recommendations and pharmacological interventions.
ANSWERS
1. What are the common signs and symptoms of iron-deficiency anemia? Fatigue Generalized weakness Dizziness or lightheadedness Headaches Chest Pain Brittle Nails Cravings for Non-Nutritive Substances (Pasricha et al., 2021) Sore or Swollen Tongue
2. Explain the laboratory findings in John Doe's case and how they support the diagnosis of iron deficiency anemia. -Hemoglobin (Hb): “9.5 g/dL (normal: 13.5–17.5 g/dL): low, indicating anemia” (Lee, 2020). -Hematocrit (Hct): 29% (normal: 40–50%): low, consistent with decreased red blood cell mass. -Serum Iron: 25 mcg/dL (normal: 60–170 mcg/dL): Low, indicating reduced iron levels in the blood.
-“Total Iron Binding Capacity (TIBC): 400 mcg/dL (normal: 250–450 mcg/dL) High, indicating the body's increased effort to bind and transport the limited available iron” (Pasricha et al., 2021). -Ferritin: 10 ng/mL (normal: 30-400 ng/mL): low, indicating depleted iron stores. -These findings support iron deficiency anemia by showing low hemoglobin and hematocrit, microcytosis (low MCV), low serum iron, high TIBC, and low ferritin levels.
3. What are the potential causes of iron deficiency anemia in adults, and how would you approach further investigations in this patient?
Potential causes:
Inadequate Dietary Intake: Insufficient iron in the diet. Increased Iron Requirements: such as during periods of rapid growth, pregnancy, or heavy menstrual bleeding. Chronic Blood Loss: Gastrointestinal bleeding (e.g., peptic ulcers, colorectal cancer), heavy menstrual periods, frequent blood donation. Malabsorption: conditions like celiac disease, Crohn's disease, or after gastric surgery.
Approach to further investigations:
Detailed History and Physical Examination: To identify any possible sources of blood loss or symptoms suggestive of malabsorption. Upper and Lower Gastrointestinal Endoscopy: To identify any sources of gastrointestinal bleeding. Assessment of Dietary Habits: To evaluate iron intake.
Evaluation for Malabsorption Syndromes: such as celiac disease testing.
4. Discuss the treatment options for iron deficiency anemia, including dietary recommendations and pharmacological interventions.
Dietary advice consists of the encouragement of increased consumption of foods rich in this mineral, including red meat, poultry, fish, lentils, beans, iron-fortified cereals, and dark green leafy vegetables. One should try to eat foods high in vitamin C, such as oranges, strawberries, broccoli, and any other foods rich in vitamin C, together with foods that are rich in iron. It’s also noteworthy that “excessive intake of foods that inhibit iron absorption, such as tea, coffee, and high-calcium foods, should not be taken around mealtimes” (Cotter et al., 2020). Pharmacological management includes oral medications such as ferrous sulfate, ferrous gluconate, and ferrous fumarate, which are taken 150– 200 mg of elemental iron per day and are best administered in divided doses. In cases where oral iron cannot be given, the patient presents with severe deficiency, or where there is malabsorption, intravenous iron can be given. Close follow-up is mandatory; the effectiveness of the therapy and compliance with the recommended dosing regimen should be evaluated using periodic measurements of hemoglobin and ferritin levels after 1-2 months of treatment.
Treatment should also involve targeting the root causes of the issues. This may entail managing existing sources of blood loss, for instance, GIB or HMB, and correcting any absorptive malfunction that might be contributing to the iron depletion. These are the common strategies that can be used to manage and treat iron-deficiency anemia.
References
Cotter, J., Baldaia, C., Ferreira, M., Macedo, G., & Pedroto, I. (2020). Diagnosis and treatment of iron-deficiency anemia in gastrointestinal bleeding: A systematic review. World journal of gastroenterology, 26(45), 7242.
Lee, N. H. (2020). Iron deficiency anemia. Clinical Pediatric Hematology-Oncology, 27(2), 101-112.
BASED ON THIS ENTIRE CASE STUDY CREATE THE SOAP NOTE
