For this Focused Note Assignment, you will select a patient with
gynecologic 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.
To prepare:
·
Use the Focused SOAP 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.
With this patient in mind, address the following in your Focused Note Template.
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_6552_Week3_Assignment2_Rubric
MUST FOLLOW RUBRIC AND TEMPLATE
Criteria Ratings Pts
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
10 to >8 pts
Excellent
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.
/ 10 pts
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
10 to >8 pts
Excellent
The response thoroughly and accurately documents the
patient’s physical exam for pertinent systems. Diagnostic tests and their
results are thoroughly and accurately documented.
/ 10 pts
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.
25 to >22 pts
Excellent
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.
/ 25 pts
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.
30 to >26 pts
Excellent
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.
/ 30 pts
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.
10 to >8 pts
Excellent
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.
/ 10 pts
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.
5 to >4 pts
Excellent
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.
/ 5 pts
