Assignment: Academic Clinical History and Physical Note 1

Assignment: Academic Clinical History and Physical Note 1

Assignment: Academic Clinical History and Physical Note 1

Assessment Description
Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.

Complete an academic clinical history and physical note based on a patient seen during clinical/practicum. In your assessment, provide the following:

History and Physical Note

ORDER A CUSTOMIZED, PLAGIARISM-FREE Assignment: Academic Clinical History and Physical Note 1 HERE

Good News For Our New customers . We can write this assignment for you and pay after Delivery. Our Top -rated medical writers will comprehensively review instructions , synthesis external evidence sources(Scholarly) and customize a quality assignment for you. We will also attach a copy of plagiarism report alongside and AI report. Feel free to chat Us

Chief complaint/reason for admission/visit/consult.
HPI for the H&P or consult notes.
Medical, surgical, family, social, and allergy history.
Home medications, including dosages, route, frequency, and current medications, if a consultation note.
Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
Vital signs and weight.
Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.
Lab/Imaging/Diagnostic test results (including date).
Assessment and Clinical Impressions

Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.
Include a complete list of all diagnoses that are both acute and chronic.
List the differential diagnoses and chronic conditions in order of priority.
Plan Component Management and Plan Criteria Incorporation

Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.
Discuss disposition and expected outcomes.
Identify and address health education, health promotion, and disease prevention.
Provide a case summary with ethical, legal, and geriatric considerations. Compare treatment options specific to the geriatric population to nongeriatric adult populations. Consider potential issues, even if they are not evident.
General Requirements

This assignment uses a template. Please refer to the “History and Physical Note Template,” located on the college page of the Student Success Center under the AGACNP tab.

Incorporate at least three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.

please make up a patient with pt diagnostic test results etc. for this assignment
sources listed for assessment and plan for pt

Academic Clinical History and Physical Note 1 – Rubric

Collapse All

History and Physical Note                                                                                                         13 points

Criteria Description

History and Physical Note (Chief Complaint, HPI, Patient History, Home Medications, Review of Systems, Vital Signs, Physical Exam, Test Results)

5. Target 13 points

The history and physical note is thoroughly explored and clearly explained with relevant details and support.

4. Acceptable 11.7points

The history and physical note is provided with appropriate details and support.

3. Approaching 10.4points

The history and physical note is present, but only minimal detail or support is provided.

2. Insufficient 6.5 points

The history and physical note is incomplete or otherwise deficient.

1. Unsatisfactory 0 points

The history and physical note is not included.

Assessment and Clinical Impressions                                                                                               13 points

Criteria Description

Assessment and Clinical Impressions (Identification of Three Differential Diagnoses, List of Acute and Chronic Diagnoses, List of Diagnoses and Conditions in Priority Order)

5. Target 13 points

The assessment and clinical impressions are thoroughly explored and clearly explained with relevant details and support.

4. Acceptable 11.7points

The assessment and clinical impressions are provided with appropriate details and support.

Plan Component Management and Criteria Incorporation                                                                                             13 points

Criteria Description

Plan Component Management and Criteria Incorporation (Interventions, Disposition, Expected Outcomes, Health Education, and Case Summary)

Peer-Reviewed Articles                                                                                                      13 points

Criteria Description

Peer-Reviewed Articles

Mechanics of Writing                                                                                                     6.5 points

Criteria Description

Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.

1. Unsatisfactory 0 points

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.

Format/Documentation                                                                              6.5 points

Criteria Description

Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.

5. Target 6.5 points

No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.

4. Acceptable 5.85points

Appropriate format and documentation are used with only minor errors.

3. Approaching 5.2 points

Appropriate format and documentation are used, although there are some obvious errors.

2. Insufficient 3.25points

Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.

1. Unsatisfactory 0 points

Appropriate format is not used. No documentation of sources is provided.

Total 65 points