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MR soap week 4 years Biological Sex: Male Race

MR soap week 4

years
Biological Sex:
Male
Race:
White, Non Hispanic

Clinical Information
Time with Patient:
30 minutes
Consult with Preceptor:
15 minutes
Type of Decision-Making:
Moderate complexity
Student Participation:
Shared (50-50)
Reason for Visit:
Follow-up (Routine)
Chief Complaint:
major depressive disorder
Social Problems Addressed:
Safety
Role Change

Procedures/Skills (Observed/Assisted/Performed)  (Critical in Bold)
General Skills – Calculate BMI (Perf)
General Skills – Measurement of height (Perf)
General Skills – Wellness/health maintenance coaching (Perf)

ICD-10 Diagnosis Codes
#1 – f32.9 - MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED

SOAP Note _______

NU___:_________

Herzing University

Name:_________________________

Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA

CC:

What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.

HPI:

Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]

PMH:

This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.

ALLERGIES

State the offending medication/food and the reactions.

MEDICATIONS

Names, dosages, and routes of administration along with indication of use.

SH

Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.

FH

Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.

HEALTH PROMOTION & MAINTENANCE

Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.

ROS

(put N/A in sections not completed day of exam)

Constitutional

Head

Eyes

Ears, Nose, Mouth, Throat

Neck

Cardiovascular/Peripheral Vascular

Respiratory

Breast

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary

Neurological

Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

Other

O: OBJECTIVE DATA

VITALS:

HR:

RR:

BP:

Temp:

SpO2%:

Ht:

Wt:

BMI:

Age:

LMP:

PAIN:

PHYSICAL EXAM

(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)

General Appearance

Head

Eyes

ENT, Mouth

Neck

Cardiovascular/Peripheral Vascular

Respiratory

Breast

Gastrointestinal

Genitourinary Male

· External Exam

· Internal Exam

Genitourinary Female

· External Exam

· Internal Exam

Musculoskeletal

Integumentary

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

Other

A: ASSESSMENT AND DIAGNOSIS

DIAGNOSIS

ICD-10 CODES

PRIORITIZE DIAGNOSIS

1.

2.

3.

VISIT CODES

CPT BILLING CODES

DIAGNOSTICS

POC TESTING

TESTS REVIEWED

P: PLAN

ACTIONS

1.

Diagnosis:

Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)

Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)

Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.

Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.

2.

Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

3.

Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

PREVENTITIVE

(Used for comprehensive exams)

Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.

FOLLOW UP

Gap analysis bev Identifying and addressing gaps between current practices

Gap analysis bev

Identifying and addressing gaps between current practices and evidence-based standards is essential to driving change. This assignment uses an adapted version of the AHRQ Gap Analysis Tool to help you evaluate a practice problem within your organization or educational setting. 

Instructions

Complete the following:

  1. Download the template: Adapted AHRQ Gap Analysis Overview and Assignment Template Download Adapted AHRQ Gap Analysis Overview and Assignment Template[PDF]
  2. Save the file to your computer. 
  3. Complete all sections of the template. 
  4. Use scholarly sources to support your best practices. 
  5. Submit the completed template. 

Assignment Resources

  • Herzing University Library (n.d.). APA Style – 7th edition: APA style and grammar guidelines.Links to an external site. 

Submit

  • Submit the completed template.
  • Follow APA guidelines for all references and citations.  
  • Direct access to articles cited is essential for grading. Either upload all evidence along with your assignment or be sure an activated link is provided within your citation so that faculty evaluators can readily access the articles that you are referencing.   

INSTRUCTIONS

Gap Analysis Tool Adapted from AHRQ

What is this tool? The purpose of the gap analysis is to provide project teams with a format in which to do the following:

• Compare the best practices with the processes currently in place in your organization. • Determine the “gaps” between your organization’s practices and the identified best

practices. • Select the best practices you will implement in your organization.

Who are the target audiences? The project liaison (you will serve as the liaison for this assignment) will be the primary individual to prepare this written gap analysis, but the entire improvement project team should be engaged in performing the gap analysis. How can the tool help you? Upon completion of the gap analysis, project teams will have the following:

• An understanding of the differences between current practices and best practice. • An assessment of the barriers that need to be addressed before successful implementation

of best practices.

How does this tool relate to others? Information from AHRQ’s Self-Assessment (Tool A.3) about the readiness of the hospital/practice setting to perform quality improvement for the Quality Indicators or Best/Evidence-based practices can be considered in the gap analysis as possible strengths or weaknesses (i.e., barriers) to be managed when implementing improvements. The best practice elements defined in the Selected Best Practices and Suggestions for Improvement (Tool D.4) are prefilled in the gap analysis tool. This provides the elements for the Implementation Plan (Tool D.6). Instructions

1. List the identified practice problem in Column 1. 2. In Column 2, provide a description of identified best practices (3 best practices required) to address the problem 4. In Column 3, identify barriers that may hinder successful implementation of each best practice strategy. Consider systems, procedures, policies, people (i.e. stakeholders), equipment, etc. 5. In Column 4, discuss your thoughts on whether your organization will implement that best practice strategy. If not, explain why. 6. Repeat steps 1-4 for each best practice.

Gap Analysis Tool (as adapted from AHRQ’s Tool D-5)

Improvement Project: _____________________ Quality Indicator/Practice Metric: ____________________________

Individual Completing This Form: ______________________________

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #1: [insert description of best practice here]

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #2: [insert description of best practice here]

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #3: [insert description of best practice here]

  1. Improvement Project:
  2. Quality IndicatorPractice Metric:
  3. Individual Completing This Form:
  4. Column 1:
  5. Column 2:
  6. Column 3:
  7. Column 4:
  8. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem:
  9. Column 1_2:
  10. Column 2_2:
  11. Column 3_2:
  12. Column 4_2:
  13. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem_2:
  14. Column 1_3:
  15. Column 2_3:
  16. Column 3_3:
  17. Column 4_3:
  18. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem_3:
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,

INSTRUCTIONS

Gap Analysis Tool Adapted from AHRQ

What is this tool? The purpose of the gap analysis is to provide project teams with a format in which to do the following:

• Compare the best practices with the processes currently in place in your organization. • Determine the “gaps” between your organization’s practices and the identified best

practices. • Select the best practices you will implement in your organization.

Who are the target audiences? The project liaison (you will serve as the liaison for this assignment) will be the primary individual to prepare this written gap analysis, but the entire improvement project team should be engaged in performing the gap analysis. How can the tool help you? Upon completion of the gap analysis, project teams will have the following:

• An understanding of the differences between current practices and best practice. • An assessment of the barriers that need to be addressed before successful implementation

of best practices.

How does this tool relate to others? Information from AHRQ’s Self-Assessment (Tool A.3) about the readiness of the hospital/practice setting to perform quality improvement for the Quality Indicators or Best/Evidence-based practices can be considered in the gap analysis as possible strengths or weaknesses (i.e., barriers) to be managed when implementing improvements. The best practice elements defined in the Selected Best Practices and Suggestions for Improvement (Tool D.4) are prefilled in the gap analysis tool. This provides the elements for the Implementation Plan (Tool D.6). Instructions

1. List the identified practice problem in Column 1. 2. In Column 2, provide a description of identified best practices (3 best practices required) to address the problem 4. In Column 3, identify barriers that may hinder successful implementation of each best practice strategy. Consider systems, procedures, policies, people (i.e. stakeholders), equipment, etc. 5. In Column 4, discuss your thoughts on whether your organization will implement that best practice strategy. If not, explain why. 6. Repeat steps 1-4 for each best practice.

Gap Analysis Tool (as adapted from AHRQ’s Tool D-5)

Improvement Project: _____________________ Quality Indicator/Practice Metric: ____________________________

Individual Completing This Form: ______________________________

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #1: [insert description of best practice here]

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #2: [insert description of best practice here]

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #3: [insert description of best practice here]

  1. Improvement Project:
  2. Quality IndicatorPractice Metric:
  3. Individual Completing This Form:
  4. Column 1:
  5. Column 2:
  6. Column 3:
  7. Column 4:
  8. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem:
  9. Column 1_2:
  10. Column 2_2:
  11. Column 3_2:
  12. Column 4_2:
  13. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem_2:
  14. Column 1_3:
  15. Column 2_3:
  16. Column 3_3:
  17. Column 4_3:
  18. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem_3:
  19. Text1:
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Healthcare Informatics: You are a DNP student preparing to present to your classmates a topic of your choice

 

You are a DNP student preparing to present to your classmates a topic of your choice. The topic you’ve chosen is locating and evaluating consumer health information. You chose this topic as it is interesting to you, and it is known that there are many types of consumer health information available, yet not all is reliable or reputable.  

Overview of the Deliverable: 

This assignment focuses on locating and evaluating consumer health information. You will prepare a 10-12 minute PowerPoint Presentation with narration that explains this topic.  

Specific Assignment Details: 

  1. Define consumer health information. 
  2. Explain how/where consumer health information is found. You should include at least three places.
  3. Explain at least three types of consumer health information.
  4. Explain the principles of evaluating consumer health information. How should it be done? What are factors to consider?
  5. Describe at least two “warning signs” that a piece of consumer health information is not reliable or may not be reputable.
  6. Include a conclusion slide to summarize the highlights of your discussion. 
  7. Use the information provided in the course as a starting point, however you should be looking for other literature and outside sources to support your presentation. At least two (2) additional sources should be used outside of the posted course materials. 
  8. This presentation should be approximately 10 minutes with no more than 5 slides. This approach encourages you to be concise while discussing these important topics. The general guideline is one minute per slide. Avoid overcrowding each slide with too much information. You may use 5-8 bullet points with main ideas, and then include supporting ideas in the speaker notes area for each slide. 
  9. The presentation should include speaker notes and demonstrate PowerPoint best practices, including the application of APA formatting. Include a title and reference slide which are not included in the total number of slides. Some helpful hints were provided previously in the course.  

Document Type/Template:

  • PowerPoint Presentation (with narration).
  • Helpful resources were provided earlier in the course on how to design a PPT with narration.  

Population Health and Emerging Disease

 

Review the case study provided of a healthcare organization that faced challenges during an outbreak of an emerging disease. Address the following components in your analysis. 

Questions: 

Leadership Evaluation 

  • Analyze the leadership strategies employed by the organization during the outbreak. What type of leadership styles were evident (e.g., transformational, transactional)? Discuss how these styles influenced the response to the emerging disease. 

Organizational Structure and Effectiveness 

  • Evaluate how the organizational structure affected the response to the emerging disease. Were there any barriers or facilitators within the organization that impacted the effectiveness of the leadership strategies? 

Impact on Population Health 

  • Assess the overall impact of the organization’s response on population health. Did the leadership strategies lead to improved health outcomes for the affected population? Provide evidence to support your evaluation. 

Document Type/Template

  • Word Document 

    Learning Theories & Principles and Quality Health Care

    Choose one learning theory and/or principle you think is most useful to the advanced practice nurse (APN) in providing high-quality health care to clients. Explain your rationale for choosing this theory and principle. 

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