Submit a written SOAP note for this case, with an assessment and plan that demonstrate critical thinking skills and application of evidence based practice.
Support your clinical decision making with at least two (2) peer-reviewed references other than required course textbooks. Explain which resources you used and which portions of the history or physical led you to the chosen diagnosis and include the evidence that supported your decision making and treatment plan.
In the presentation, include how you incorporated a holistic approach and how you applied one of Jean Watson’s ten carative factors into your care of this patient.Include the following in your oral presentation:
Introduction
Your name
Your clinical site/type and location
Brief descriiption of the case (ID, CC, brief HPI)
Describe why the case was meaningful, memorable, interesting, or challenging to you
Presentation of case (brief)
Subjective information
ID, CC, HPI
PMH, SH, FH
ROS
Objective Information
Vital Signs (if all are normal, it is ok to say so)
Physical Exam (only describe pertinent findings, otherwise it is ok to say unremarkable)
Pertinent recent diagnostics (if available)
Assessment
Differentials you considered
Resources used to narrow the differentials
Your critical thinking process
Final diagnosis and any secondary diagnoses
Plan
Diagnostic, therapeutic, educational and follow up components
Application of evidence based practice
Why did you select the chosen therapy/referral/diagnostic approach
What support is there for your plan
What alternatives were considered
Holistic Approach and Caring Science
Provide examples of how you collaborated or could have collaborated with the patient, family, or other members of the care team to achieve better healthcare outcomes. Include cultural considerations.
Which of Jean Watson’s Caring Processes were considered with this patient?
In what ways was your care of this patient representative of a holistic approach?
