Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly learning resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will work with a patient with a HEENT condition that you examined during the last three weeks, and complete an Episodic/Focus Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. In this week’s Learning Resources, please refer to the Focused SOAP Note resources for guidance on writing Focused Notes.
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 Turnitin.
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.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
To prepare:
Use the Episodic/Focus Note Template found in the Learning Resources for this week to complete this assignment.
Select a patient that you examined during the last three weeks that suffered from any HEENT condition. With this patient in mind, address the following in a Focused Note:
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.
Reflection notes: What would you do differently in a similar patient evaluation?
PRAC_6531_Week3_Assignment2_Rubric
PRAC_6531_Week3_Assignment2_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeOrganization of Write-up
10 to >6.0 pts
Excellent
All information organized in logical sequence; follows acceptable format and utilizes expected headings.
6 to >3.0 pts
Good
Information generally organized in logical sequence; follows acceptable format and utilizes expected headings.
3 to >0.0 pts
Fair
Errors in format; information intermittently organized. Headings are used some of the time.
0 pts
Poor
Errors in format; information disorganized. Headings are not used appropriately.
10 pts
This criterion is linked to a Learning OutcomeThoroughness of History
20 to >15.0 pts
Excellent
Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information.
15 to >11.0 pts
Good
Documents most pertinent examination components.
11 to >7.0 pts
Fair
Documents some pertinent examination components.
7 to >0 pts
Poor
Physical examination cursory; misses several pertinent components.
20 pts
This criterion is linked to a Learning OutcomeHistory of Present Illness
10 to >6.0 pts
Excellent
Thoroughly documents all 8 aspects of HPI and pertinent other data relevant to chief complaint. Includes critical as well as supportive information.
6 to >4.0 pts
Good
Documents at least 6 aspects of the HPI and pertinent other data relevant to chief complaint. Includes critical information.
4 to >2.0 pts
Fair
Documents at least 4 aspects of HPI and some data pertinent to chief complaint. Lacks some critical information or rambling in history.
2 to >0 pts
Poor
Missing many aspects of HPI and pertinent data. Critical information missing.
10 pts
This criterion is linked to a Learning OutcomeThoroughness of Physical Exam
10 to >7.0 pts
Excellent
Thoroughly documents all pertinent examination components for type of note.
7 to >4.0 pts
Good
Documents most pertinent examination components.
4 to >2.0 pts
Fair
Documents some pertinent examination components.
2 to >0 pts
Poor
Physical examination cursory; misses several pertinent components.
10 pts
This criterion is linked to a Learning OutcomeDiagnostic Reasoning
10 to >7.0 pts
Excellent
Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests.
7 to >4.0 pts
Good
Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.
4 to >2.0 pts
Fair
Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests.
2 to >0 pts
Poor
Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests.
10 pts
This criterion is linked to a Learning OutcomeTreatment Plan/Patient Education
20 to >15.0 pts
Excellent
Treatment plan addresses all issues raised by diagnoses, excellent insight into patient’s needs. Medications prescribed are appropriate and full prescription is included. Evidence based decisions. Cost effective treatment.
15 to >10.0 pts
Good
Treatment plan addresses most issues raised by diagnoses. Medications prescribed are appropriate but include 1 or 2 error in writing prescription.
10 to >5.0 pts
Fair
Treatment plan fails to address most issues raised by diagnoses. Medications are inappropriate or include 3 or more errors in writing prescription.
5 to >0 pts
Poor
Minimal treatment plan addressed. Medications are inappropriate or poorly written prescription.
20 pts
This criterion is linked to a Learning OutcomePatient Education / Follow Up / Reflection
10 to >8.0 pts
Excellent
Patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Follow up plan in appropriate and reflects acuity of illness. Reflection is thoughtful and in depth.
8 to >5.0 pts
Good
Patient education addresses most issues raised by diagnoses. Follow up plan is appropriate but lacks specifics Reflection is thoughtful and in depth.
5 to >3.0 pts
Fair
Patient education fails to address most issues raised by diagnoses. Follow up plan is lacking specifics or is inappropriate for patient acuity. Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.
3 to >0 pts
Poor
Minimal patient education addressed. Follow up plan is inappropriate Reflection is absent.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation. Professional language utilized
5 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors. Professional language utilized.
4 pts
Good
Contains a few (1-2) grammar, spelling, and punctuation errors. Contains a few errors (1 or 2) in professional language use.
2 pts
Fair
Contains several (3-4) grammar, spelling, and punctuation errors. Contains several errors (3 -4) in professional language use.
0 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Contains many errors in professional language use.
5 pts
This criterion is linked to a Learning OutcomeScholarly References and Clinical Practice Guidelines. The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Clinical practice guidelines are included if applicable.
5 pts
Excellent
Contains parenthetical/in-text citations and at least 3 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.
4 pts
Good
Contains parenthetical/in-text citations and at least 2 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.
2 pts
Fair
Contains parenthetical/in-text citations and at least 1 evidenced based reference less than 5 years old is listed. Clinical practice guidelines are not cited if applicable.
0 pts
Poor
Contains no parenthetical/in-text citations and 0 evidenced based references listed. Clinical practice guidelines are not cited if applicable.
5 pts
