Assignment: PRAC 6531 Episodic Visit: Gastrointestinal Focused Note

Assignment: PRAC 6531 Episodic Visit: Gastrointestinal Focused Note

Assignment: PRAC 6531 Episodic Visit: Gastrointestinal Focused Note

Episodic Visit: Gastrointestinal Focused Note

For this Assignment, you will work with a patient with a gastrointestinal condition that you examined during the last three weeks. You will complete your second Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, PMH, socioeconomic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.

ORDER A PLAGIARISM-FREE PAPER HERE ON; Assignment: PRAC 6531 Episodic Visit: Gastrointestinal Focused Note

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

Learning Resources

Required Readings

Fowler, G. C. (2020). Pfenninger and Fowler’s procedures for primary care (4th ed.). Elsevier.

Chapter 82, “Clinical Anorectal Anatomy and Digital Examination” (pp. 570–572)

Chapter 83. “Anoscopy” (pp. 573–576)

Chapter 87, “Office Treatment of Hemorrhoids” (pp. 596–606) specifically pp. 604 -606 external hemorrhoidal tags

Chapter 94, “Esophageal Foreign Body Removal” (pp. 676–679)

Chapter 95, “Inguinal Hernia Reduction” (pp. 680–683)

Chapter 20,: “Management of Fecal Impaction” (pp. 1382–1383)

Practicum Resources

HSoft Corporation. (2019). Meditrek: Home

Links to an external site.. https://edu.meditrek.com/Default.html

Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.

Walden University Field Experience. (2019a). Field experience: College of Nursing.

Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/home

Walden University Field Experience. (2019b). Student practicum resources: NP student orientation.

Links to an external site. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation

Walden University. (2019). MSN nurse practitioner practicum manual.

Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments

Document: Episodic/Focus Note Template (Word document)

Download Episodic/Focus Note Template (Word document)

To prepare:

Use the Episodic/Focused 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 based on any gastrointestinal conditions. 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?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 6.

By Day 7

Submit your Episodic/Focused Note Assignment. (Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6.)

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

To submit your completed assignment, save your Assignment as WK6Assgn2_LastName_Firstinitial

Then, click on Start Assignment near the top of the page.

Next, click on Upload File and select Submit Assignment for review.

Rubric

PRAC_6531_Week6_Assignment2_Rubric

PRAC_6531_Week6_Assignment2_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning Outcome Organization of Write-up

30 to >26.0 pts
Excellent

All information organized in logical sequence; follows acceptable format

26 to >23.0 pts
Good

Information generally organized in logical sequence; follows acceptable format

23 to >20.0 pts
Fair

Errors in format; information intermittently organized

20 to >0 pts
Poor

Errors in format; information disorganized

30 pts

This criterion is linked to a Learning Outcome Thoroughness of History

20 to >17.0 pts
Excellent

Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information

17 to >15.0 pts
Good

Documents most pertinent history components; includes critical information

15 to >13.0 pts
Fair

Fails to document most pertinent history components; Lacks some critical information or rambling in history

13 to >0 pts
Poor

Minimal history; critical information missing

20 pts

This criterion is linked to a Learning Outcome Thoroughness of Physical Exam

10 to >8.0 pts
Excellent

Thoroughly documents all pertinent examination components for type of note

8 to >7.0 pts
Good

Documents most pertinent examination components

7 to >6.0 pts
Fair

Documents some pertinent examination components

6 to >0 pts
Poor

Physical examination cursory; misses several pertinent components

10 pts

This criterion is linked to a Learning Outcome Diagnostic Reasoning

10 to >8.0 pts
Excellent

Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests

8 to >7.0 pts
Good

Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.

7 to >6.0 pts
Fair

Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests

6 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 Outcome Treatment Plan/Patient Education

10 to >8.0 pts
Excellent

Treatment plan and patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Evidence based decisions. Cost effective treatment. Reflection is thoughtful and in depth.

8 to >7.0 pts
Good

Treatment plan and patient education addresses most issues raised by diagnoses. Reflection is thoughtful and in depth.

7 to >6.0 pts
Fair

Treatment plan and patient education fail to address most issues raised by diagnoses. … Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.

6 to >0 pts
Poor

Minimal treatment plan and/or patient education addressed … Reflection is absent.

10 pts

This criterion is linked to a Learning Outcome Written Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.

10 to >8.0 pts
Excellent

Uses correct grammar, spelling, and punctuation with no errors.

8 to >7.0 pts
Good

Contains a few (1-2) grammar, spelling, and punctuation errors.

7 to >6.0 pts
Fair

Contains several (3-4) grammar, spelling, and punctuation errors.

6 to >0 pts
Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

10 pts

This criterion is linked to a Learning Outcome Written Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.

10 to >8.0 pts
Excellent

Contains parenthetical/in-text citations and at least 3 evidenced based references are listed.

8 to >7.0 pts

Good

Contains parenthetical/in-text citations and at least 2 evidenced based references are listed

7 to >6.0 pts
Fair

Contains parenthetical/in-text citations and at least 1 evidenced based reference is listed

6 to >0 pts
Poor

Contains no parenthetical/in-text citations and 0 evidenced based references listed.

10 pts

Total Points: 100