Assignment: PRAC 6631 Week 3 Episodic Visit: HEENT Focused Note

Assignment: PRAC 6631 Week 3 Episodic Visit: HEENT Focused Note

Assignment: PRAC 6631 Week 3 Episodic Visit: HEENT Focused Note

EPISODIC VISIT: HEENT FOCUSED NOTE

Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly learning resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

ORDER A PLAGIARISM-FREE PAPER HERE ON; Assignment: PRAC 6631 Week 3 Episodic Visit: HEENT Focused Note

For this Assignment, you will work with a patient with a HEENT condition that you examined during the last three weeks, and complete an Episodic/Focus Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. In this week’s Learning Resources, please refer to the Focused SOAP Note resources for guidance on writing Focused Notes.

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.

Section 4: Eyes, Ears, Nose, and Throat

Chapter 62, “Cerumen Impaction Removal” (pp. 388–392)

Section 13: Urgent Care

Chapter 200, “Corneal Abrasions and Removal of Corneal or Conjunctival Foreign Bodies” (pp. 1338–1344)

Chapter 201, “Slit-Lamp Examination” (pp. 1345–1349)

Chapter 202, “Auricular Hematoma Evacuation” (pp. 1350–1354)

Chapter 204, “Removal of Foreign Bodies from the Ear and Nose” (pp. 1359–1364)

Chapter 205, “Management of Epistaxis (pp. 1365–1371)

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 NursingLinks 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)

Required Media

SOAP Notes

In this media program, Dr. Nancy Hadley discusses the expectations for developing a SOAP note. (27m)

To prepare:

Use the Episodic/Focus 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 that suffered from any HEENT condition. 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 3.

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 3.)

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 WK3Assgn2_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_Week3_Assignment2_Rubric

PRAC_6531_Week3_Assignment2_Rubric
Criteria Ratings Pts

This criterion is linked to a Learning OutcomeOrganization 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 OutcomeThoroughness 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 OutcomeThoroughness 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 OutcomeDiagnostic 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 OutcomeTreatment 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 OutcomeWritten 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 OutcomeWritten 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

PreviousNext