Wilkes University
Passan School of Nursing
NSG 550: Diagnostic Reasoning for Nurse Practitioners
Clinical Note Guidelines
Each student will complete a clinical note utilizing the framework of a comprehensive health history and physical examination. The written assignment is documentation of the findings and should demonstrate application of course content and follow the criteria provided below. This should be in a charting format and no longer than 3 pages, excluding a title and reference page. Five points will be deducted for assignments longer than the stated criteria. APA not required so single spacing is allowed. Mastering succinctness of communication, both written and verbal of clinical reasoning, is critical to the process of becoming a nurse practitioner.
Content
Grade Percentage
Choose a patient to perform the H and P; this person could be a family member or patient from your clinical practice.
Only use initials when identifying the patient.
5%
Chief Complaint and History of Present Illness
5%
Past Medical and Surgical History
5%
Medications and Allergies
5 %
Family History
5%
Social History
5%
Review of Systems (subjective-complete review of systems including pertinent positive and negative findings as per the patient-what did the patient say)
15%
Physical Examination (objective-complete PE including pertinent positive and negative PE findings).
15%
Assessment and Plan (You can make one section with the Assessment/Plan or you can keep them as separate sections).
Provide all possible diagnoses based upon clinical decision making listing the one with the highest probability first.
Provide comprehensive treatment plan and communicate clinical reasoning; utilize theory from NSG500, 550, 530, and 533. Provide clinical support/citations.
35%
Provides references of peer reviewed, scholarly citations
5%
Total
100%
Criteria for this written assignment can be found on the next page. This information was introduced in NSG 500.
History—Subjective Data
ID
Age, gender, DOB
CC
Reason for seeking care-patient’s own words
HPI
O-onset
L-location
D-duration
C-character
A-aggravating/associated factors
R-relieving factors
T-temporal factors
S-severity
Medications, treatments
PMH/PSH
General health, surgeries, hospitalizations, illnesses, immunizations, medications, allergies, blood transfusions, emotional status/psychiatric history
Personal History
Cultural background, marital status, occupation, economic resources, environment
Health Habits
Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins
Health Maintenance
Last PE; diagnostic tests (date, result, follow-up); self-exams (breast, genital, testicular); last Pap smear, mammogram
Family History
(Parents, siblings, children)
Cancer, DM, hypertension, heart disease, stroke
REVIEW OF SYSTEMS
General
Fever, chills, malaise, fatigue/energy, night sweats, desired weight
Diet
Appetite, restrictions, vitamins, supplements
Skin, Hair, Nails
Rash, eruptions, itching, pigment changes
Head and Neck
Headaches, dizziness, head injuries, loss of consciousness
Eyes
Blurring, double vision, visual changes, glasses, trauma, eye diseases
Ears
Hearing loss, pain, discharge, vertigo, tinnitus
Nose
Congestion, nosebleeds, postnasal drip
Throat and Mouth
Hoarseness, sore throat, bleeding gums, ulcers, tooth problems
Gastrointestinal
Indigestion, heartburn, vomiting, bowel regularity/changes
Lymph
Tenderness, enlargement
Endocrine
Heat/cold intolerance, weight change, polydipsia, polyuria, hair changes, increased hat, glove, or shoe size
Female
LMP, age at menarche, gravity, parity, menses (onset, regularity, duration, symptoms), sexual life (number of partners, satisfaction), contraception, menopause (age, symptoms)
Male
Puberty onset, erections, testicular pain, libido, infertility
Breasts
Pain, tenderness, lumps, discharge
Chest and Lungs
Cough, sputum, shortness of breath, dyspnea on exertion, night sweats, exposure to TB
Cardiovascular
Chest pain, palpitations, number of pillows, edema, claudication, exercise tolerance
Hematology
Anemia, easy bruising
Genitourinary
Dysuria, flank pain, urgency, frequency, nocturia, hematuria, dribbling
Musculoskeletal
Joint pain, heat swelling
Neurologic
Fainting, weakness, loss of coordination
Mental Status
Concentration, sleeping, eating, socialization, mood changes, suicidal thoughts
Physical Examination—Objective Data
VS
TPR, BP, Ht, Wt, BMI, Pulse Ox
General Appearance
Age, race, gender, posture and gait
Mental Status
Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality
Skin
Color, integrity, hygiene, turgor, hydration, edema, lesions, hair distribution and texture, nail texture, nail base angle
Head
Scalp, temporal arteries, deformities
Neck
Trachea (position, tug), range of motion (ROM), carotid bruit, jugular venous distention (JVD), thyroid, lymph (head and neck)
Eyes
Pupils (PERRLA), eyelids, conjunctivae, sclerae, EOMs (CN III, IV, VI), light reflex, visual fields, funduscopy (CN II), acuity (CN II), nystagmus
Ears
Deformities, lesions, discharge, otoscopy (canal, TM), hearing (Rinne, Weber, CN VIII)
Nose
Mucosa, septum, turbinates, discharge, sinus area swelling or tenderness
Mouth and Throat
Lips/teeth/gums, tongue (CN XII), mucosa, palates, tonsils, exudate, uvula, gag reflex (CN IX, X)
Chest/Lungs
Shape, movement, respirations (rate, rhythm), expansion, accessory muscles, tactile fremitus, crepitus, percussion tone, excursion, auscultation (clear, wheeze, crackles, rhonchi, rubs)
Breasts
Contour, symmetry, nipples, areolae, discharge, lumps/masses, lymph (axillary, supraclavicular, and infraclavicular)
Heart
PMI, lifts, thrills, rate, rhythm, S1, S2, splitting, gallops, rubs, murmurs, snaps
Blood Vessels
Cyanosis, clubbing, edema, peripheral pulses, skin, nails
Abdomen
Contour, symmetry, skin, bowel sounds, bruits, hum, liver span, liver border, tenderness, masses, spleen, kidneys, aortic pulsation, reflexes, percussion tone, costovertebral angle (CVA) tenderness, femoral pulses, lymph (inguinal)
Male Genitalia
Pubic hair, glans, penis, testis, scrotum, epididymis, urethral discharge, hernias
Female Genitalia
External lesions or discharge, Bartholin and Skene glands, urethra, vaginal walls, cervix (position, lesions, cervical motion tenderness), uterus, adnexa
Rectum/Prostate
Sacrococcygeal and perineal areas, anus, sphincter tone, rectal walls, masses, fecal occult blood test (FOBT)
Male: Prostate
Female: Rectovaginal septum, uterus
Musculoskeletal
Posture, alignment, symmetry, joint heat/swelling/color, muscle tone, ROM, strength
Neurologic
CN II-XII, rapid alternating movements, finger-to-nose, sensation, vibration, stereognosis, motor system, gait, Romberg, deep tendon reflexes (DTRs), superficial reflexes
Cranial Nerves
I: Smell
II: Visual acuity, visual fields, funduscopy
III, IV, VI: Eyelid opening EOMs: IV up and out, VI lateral, III all others
V: Corneal reflex, facial sensation (3 areas), jaw opening, bite strength
VII: Eyebrow raise, eyelid close, smile, taste
VIII: Rinne, Weber
IX, X: Gag reflex, palate elevation, phonation
XI: Lateral head rotation, neck flexion, shoulder shrug
XII: Tongue protrusion, lateral deviation strength
Assessment
Diagnosis(es)-clinical reasoning
Plan
Treatment; rationale
