Week 3 Assignment

Practicum Experience: SOAP Note and Time Log
In aIDition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes.
After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, aIDress the following in a SOAP Note:
€¢    Subjective: What details did the patient provide regarding his or 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?
€¢    Reflection notes: What would you do differently in a similar patient evaluation?
Week 3 Learning Resources
This page contains the Learning Resources for this week. Be sure to scroll down the page to see all of this week’s assigned Learning Resources.
Required Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Readings
€¢    Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.
o    Part 11, Evaluation and Management of Cardiovascular Disorders (pp. 487€“611)

This part explores diagnostics of cardiovascular disorders, including how to differentiate between normal and abnormal test results. It also examines how patient history and physical exams contribute to differential diagnoses for cardiovascular disorders.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.
o    Chapter 26, Recording Information

This chapter outlines the components of SOAP notes and provides guidelines for writing SOAP notes after patient examinations. Please note: You should have this textbook in your personal library, as it was the required text in NURS 6511: Advanced Health Assessment & Diagnostic Reasoning.
Gagan, M. J. (2009). The SOAP format enhances communication. Nursing New Zealand, 15(5), 15.
Retrieved from the Walden Library databases.

This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings.
National Heart Lung and Blood Institute. (2002). Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. Retrieved fromhttp://www.nhlbi.nih.gov/health/prof/heart/hbp/pphbp.pdf

This article reviews factors that impact the patient education of hypertension. Hypertension prevention and intervention methods are also explored.
Optional Resources
€¢    American Heart Association. (n.d.). Retrieved November 28, 2012, fromhttp://www.heart.org/HEARTORG/
€¢    Drugs.com. (n.d.). Retrieved November 28, 2012, from www.drugs.com
€¢    Institute for Safe Medication Practices. (n.d.). Retrieved November 28, 2012, fromhttp://www.ismp.org/
€¢    Million Hearts. (n.d.). Retrieved November 28, 2012, from http://millionhearts.hhs.gov/index.html
€¢    WebMD. (2012). Medscape. Retrieved from http://www.medscape.com/

SOAP NOTE TEMPLATE

Select a patient that you have examined in the clinical setting to complete a SOAP Note.You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source).  Please include a heart exam and lung exam on all clients regardless of the reason for seeking care.  So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam.  The pertinent positive and negative findings should be relevant to the chief complaint and health history data.  This template is a great example of information documented in a real chart in clinical practice. The term Rule Out€¦ cannot be used as a diagnosis. Please describe appearance of area assessed and refrain from using the term normal when documenting this note.

I.    Subjective Data

A.    Chief Complain (CC): A single statement in patient’s own words with quotations that include timing.  Example:  My head has been hurting for 2 days

B.    History of Present Illness (HPI): Use OLDCARTS pneumonic to document this data.  Please see sample HPI in Docsharing

C.    Last Menstrual Period (LMP- if applicable)

D.    Allergies:

E.    Past Medical History:

F.    Family History:

G.    Surgery History:

H.    Social History (alcohol, drug or tobacco use):

I.    Current medications:

J.    Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI.  Please do not include exam findings in this section; only document patient or caregiver’s answer to your history questions)

II.    Objective Data

Please remember to include an assessment of all relevant systems based on the CC and HPI.  The following systems are required in all SOAP notes.  You will proceed to assess aIDitional pertinent systems.

Vital Signs/ Height/Weight:

General Appearance:

HEART:

RESP:

A.    Assessment

Differential Diagnosis (include rationales and cite source)

1.
2.
3.

Medical Diagnosis

1.

B:  PLAN

1.    Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2.    Diagnostic testing
3.    Health Education/Promotion/Maintenance Needs
4.    Referrals

Follow-Up Plans (When will you schedule a follow-up appointment and what will you aIDress in the subsequent visit; Example €”F/U in 2 weeks; Plan to repeat CXRAY on RTC (return to clinic)

Reflection:  What was your aha moment? What would you do differently in a similar patient evaluation?

References:  Please include at least 3 evidence-based sources in APA format.

NURS 6531 Practicum Experience Time Log and Journal Template

Student Name:

E-mail AIDress:

Practicum Placement Agency’s Name:

Preceptor’s Name:

Preceptor’s Telephone:

Preceptor’s E-mail AIDress:

(Continued next page)
Time Log

List the objective(s) met and briefly describe the activities you completed during each time period. If you are not on-site for a specific week, enter Not on-site for that week in the Total Hours for This Time Frame column. Journal Entries are due in Weeks 4, 8, and 11; include your Time Log with all hours logged (for current and previous weeks) each time you submit a Journal Entry.

You are encouraged to complete your practicum hours on a regular schedule, so you will complete the required hours by the.end of week 11

NURS 651 Time Log
Week
Dates    Times
Total Hours for This
Time Frame    Activities/Comments     Learning Objective(s) AIDressed
3    9-17-14        8:00-17:00
3    9-18-14        8:00:17:00

Students will:
€¢    Assess patients with histories of hypertension
€¢    Evaluate health promotion strategies for patients with hypertension
€¢    Evaluate the impact of patient factors on treatments and health promotion strategies
€¢    Understand and apply key terms, concepts, and principles related to the evaluation and management of cardiovascular disorders
€¢    Assess diagnoses for patients
€¢    Evaluate treatment and management plans

Journal Entries
€¢    Include references immediately following the content.
€¢    Use APA style for your Journal Entry and references.