see attached.
I filled in the information obtained in the lab.
Need assessment and plan sections- i placed * next to things that need to be included.
This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on the patient Desiree Allen seen in Unit 2 in the VR platform.
Write-ups
The SOAP note serves several purposes:
1. It is an important reference document that provides concise information about a patient’s history and exam findings at the time of patient visit.
2. It outlines a plan for addressing the issues which prompted the office visit. This information should be presented logically and prominently features all of the data that’s immediately relevant to the patient’s condition.
3. It is a means of communicating information to all providers involved in the care of a particular patient.
4. It allows the NP student to demonstrate their ability to accumulate historical and examination-based information, use their medical knowledge, and derive a logical plan of care.
Knowing what to include and what to leave out will largely depend on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the SOAP notes you create and reading those written by more experienced practitioners.
The core aspects of the SOAP note are described in detail below.
For ease of learning, a
SOAP note template
has been provided. This assignment requires proper citation and referencing because it is an academic paper.
S: Subjective information. Everything the patient tells you. This includes several areas, including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.
O: Objective is what you see, hear, feel or smell. Your physical exam, including vital signs.
A: Assessment/your differentials
P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.
Rubric Title: Unit 2, 4, 6 Lab – Virtual Reality Rubric
***Students: It is IMPORTANT to remember to utilize both the “Guided Mode” and “Expert Mode” in the VR Lab Simulation case scenario experiences, as you practice the VR Lab scenario(s). The “Guided Mode” and “Expert Mode” allow you to have multiple tries/attempts to practice the case. THEN, when you feel you are ready, you will choose the VR Lab “Exam Mode” (that you can ONLY attempt once); the score you receive in “Exam Mode” will then be your final grade in the VR Lab. If you have any questions regarding this, please follow up with your course instructor.
Assignment Criteria |
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Level III |
Level II |
Level I |
Not Present |
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Criteria 1 |
Level III Points: 8 0 |
Level II Points: 64 |
Level I Points: 48 |
Not Present |
0 Points |
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Total Score |
· Within Exam Mode, obtains 65 to 80 points of the required total components for virtual reality patient scenario |
· Within Exam Mode, obtains between 49 to 64.9 points of the required total components for virtual reality patient scenario |
· Within Exam Mode, obtains between 33 to 48.9 points of the required total components for virtual reality patient scenario |
· Does not attempt in Exam Mode |
· Does not meet the criteria |
Rubric Title: Unit 3, 5, 7 Journal Assignment Rubric
Criteria 1 |
Level III Max Points Points: 6 |
Level II Max Points Points: 4.8 |
Level I Max Points Points: 4.2 |
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Content Quality- Subjective Data |
Subjective data displays complete understanding of all critical concepts of virtual reality patient case including: · Name, age, gender · Chief complaint · History of present illness (HPI) that follows OLD CARTS pneumonic · Medications · Allergies · Past medical history · Past surgical history · Pertinent family history · Social history · Review of Systems |
· Subjective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details. |
· Subjective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details. |
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Criteria 2 |
Not Present 0 Points |
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Content Quality- Objective Data |
Objective data displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Vital signs · Body systems that are pertinent to specific case |
· Objective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details. |
· Objective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details |
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Criteria 3 |
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Content Quality- Assessment |
Assessment displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Primary diagnosis · Pathophysiology of primary diagnosis · Three differential diagnoses · Rationales for differential diagnoses |
· Assessment displays understanding of critical concepts of chosen virtual reality patient case; there may be onecritical concept with errors/omissions or lack of details. |
· Assessment displays understanding of critical concepts of chosen virtual reality patient case; there may be two critical concepts with errors/omissions or lack of details. |
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Criteria 4 |
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Content Quality- Plan of Care |
Plan displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Medications · Non-pharmacological recommendations · Diagnostic tests · Patient education · Cultural considerations · Health promotion · Referrals · Follow-Up |
· Plan displays understanding of critical concepts of chosen virtual reality patient case; there may be one critical concept with errors/omissions or lack of details. |
· Plan displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details. |
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Criteria 5 |
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Collegiate-level academic writing |
· Includes no more than three grammatical, spelling, or punctuation errors that do not interfere with the readability. · Supports all opinions and ideas with relevant and credible reference sources of information. · Provides three or more peer-reviewed or evidence-based practice scholarly references sources. · All reference sources are within the past five years. |
· Includes no more than four grammatical, spelling, or punctuation errors that do not interfere with the readability. · Supports many opinions and ideas with relevant and credible sources of information. · Provides two peer-reviewed or evidence-based practice scholarly references sources. · All reference sources are within the past five years. |
· Includes five or more grammatical, spelling, and punctuation errors that makes understanding parts of assignment difficult, but does not interfere with readability. · Not all references utilized are relevant and/or credible sources of information. · Provides one peer-reviewed or evidence-based practice scholarly references source. · Reference sources are within the past five years. |
· Does not the meet criteria |
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Criteria 6 |
Level III Max Points Points: 5 |
Level II Max Points Points: 4 |
Level I Max Points Points: 3 |
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Citations and Formatting |
● The overall order of information is clear and contributes to the meaning of the assignment. ● There may be 1-2 sentences, or one paragraph that is out of order, or other minor organization issues. ● Strong attempt at APA formatting and correctly citing all reference sources. One or two formatting, in-text, or reference citation errors may occur. ● Quotation marks and citations make authorship clear. |
● The overall order of information is confusing in places due to 3-4 sentences, or two paragraphs that may be out of order, or other organization issues that interfere with the meaning or intent of the paper. ● Overall attempt at APA formatting and correctly citing all reference sources. 3-4 formatting, in-text, or reference citation errors may occur. ● Quotation marks and citations generally, make authorship clear. |
● The overall order of information is confusing in places due to 5-6 sentences or three paragraphs that may be out of place, or other organization issues that interfere with the meaning or intent of the paper. ● Attempts to use APA formatting and citing. 5-6 formatting, in-text, or reference citation errors may occur. ● Quotation marks and citations may be missing or incorrect. ● Authorship may be unclear in areas. |
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Maximum Total Points |
35 |
28 |
24 |
0 | |||||||||||
Minimum Total Points |
29 |
25 |
1 |
Rubric Title: Unit 8 Journal Rubric
Criteria 1 |
Level III Max Points Points: 15 |
Level II Max Points Points: 12 |
Level I Max Points Points:9 |
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Presentation of subjective data displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Name, age, gender |
· Presentation of subjective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details. |
· Presentation of subjective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details. |
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Presentation of objective data displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Vital signs |
· Presentation of objective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details. |
· Presentation of objective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details. |
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Presentation of assessment displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Primary diagnosis |
· Presentation of assessment displays understanding of all critical concepts of chosen virtual reality patient case; there may be one critical concept with errors/omissions or lack of details. |
· Presentation of assessment displays understanding of all critical concepts of chosen virtual reality patient case; there may be two critical concepts with errors/omissions or lack of details. |
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Presentation of plan displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Medications · Non-pharmacological management · Diagnostic tests |
· Presentation of plan displays understanding of all critical concepts of chosen virtual reality patient case; there may be one critical concept with errors/omissions or lack of details. |
· Presentation of plan displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.s |
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Quality of Oral Presentation |
· Presentation demonstrated thorough organization and delivery. · All ideas were stated in a clear and logical manner. · Presentation was on topic and relevant. · Presentation time no longer than 5 minutes |
· Presentation was organized and well spoken. · All ideas were stated in a clear and logical manner. · Presentation >5 minutes |
· Presentation needed more details or content inconclusive. · Presentation >5 minutes |
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75 |
60 |
45 |
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61 |
46 |
image1
Name:
Desiree J. Allen |
Pt. Encounter Number:2 |
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Date: 1/17/23 |
Age: 29 |
Sex: F |
SUBJECTIVE |
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CC: “Heavy periods”
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HPI: 29 yo G1P1 Caucasian female, history of incomplete L2 spinal cord injury resulting in paraplegia. History of heavy flow since onset of menses and presence of symptoms for one quarter of her life, now soaking super absorbency pad every 3 hours. Menses lasts one week or more. Reports flow is lighter for a couple days leading up and few days at the end however 5-6 days of heavy flow. Associated symptoms include lower abdominal pain, headache, body aches, fatigue and digestive issues including nausea and bloating. Has been seen by physician in past. Work up included Transvaginal ultrasound last year, results normal and endometrial biopsy normal. Was prescribed progestin-only pill but had difficulty with medication compliance. Has tried increased water intake, rest, healthier eating and PRN Midol use with no improvement. Has not identified any pattern to worsening symptoms. Describes symptoms as intense, unmanageable, pain severity 8/10. Unable to use tampons due to limited mobility and seeking alternate method to shorten and lighten menstrual flow.
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Medications: Ibuprofen 600mg PRN generalized pain
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Allergies:
Medication Intolerances: none reported |
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Past Medical History: Incomplete spinal cord injury L2 x 1 year, menorrhagia
Chronic Illnesses/Major traumas Spinal cord injury 1 year ago due to MVA resulting in paraplegia, patient is wheelchair bound.
Hospitalizations/Surgeries Spinal cord decompression 2022 following MVA, hospitalized x 3 weeks followed by 30 stay inpatient rehab. Term pregnancy (40 weeks) with normal spontaneous vaginal delivery 4 years ago Preventative Health: Normal PAP one year ago. COVID UTD. TDAP 2 years ago.
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Family History Brother-PTSD Mother-Hyperlipidemia Father- HTN
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Social History Pronouns used -she, her, hers. Completed 4-year degree in telecommunications. Currently unemployed and on disability. Previously worked in sales for a radio station which she enjoyed and hopes to return to someday. She is married and lives in a ground floor, handicap accessible apartment with her husband and daughter. She feels safe in her home environment. Denies tobacco or illicit drug use. Reports only occasional EtOH use. She is sexually active with husband although she reports challenges due to limited mobility and decreased sensation. Due to limited mobility, exercise is limited.
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ROS Student to ask each of these questions to the patient: “Have you had any…..” |
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General Well groomed, interacts appropriately. Denies weight changes but reports wanting to lose a few lbs .Reports fatigue during menses. Denies fever, chills.
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Cardiovascular Denies CP, palpitations, denies edema. Does report limited cardiovascular exertion due to limited mobility. |
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Skin Denies skin breakdown, uses moisturizers on bony prominences and repositions frequently. Denies bruising.
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Respiratory Denies cough, SOB. No history of pneumonia or TB.
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Eyes Denies. |
Gastrointestinal Reports nausea, bloating and digestive issues during menses. Otherwise denies abdominal pain, N/V/D. Reports eating a healthy diet. Denies history of bloody stools.
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Ears Denies.
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Genitourinary/Gynecological Denies any difficulty with urination. Reports heavy periods, states menses have always been heavy and now changes super absorbency pad every 3 hours. Sexually active with husband, limited due to decreased mobility and sensation Husband had vasectomy. Last PAP 1 year ago, normal G1 P1, normal vaginal delivery at 40 weeks gestation.
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Nose/Mouth/Throat Denies. |
Musculoskeletal Occasional muscle spasms and generalized pain, relief obtained with PRN Flexeril and Ibuprofen. |
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Breast Performs monthly SBE, no lumps, bumps or changes reported. |
Neurological Responds appropriately, oriented x 4. Denies syncope. Paraplegia BLE. |
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Heme/Lymph/Endo Denies history of bruising. Never had blood transfusion. Denies history of anemia. Denies swollen glands. |
Psychiatric Denies depression and describes herself as positive person. Denies anxiety or history of suicidal ideation. |
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OBJECTIVE |
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Weight 105lbs BMI 20.1 |
Temp 98.3F oral |
BP 110/68 |
Height 5’2” |
Pulse 82 |
Resp 14 |
General Appearance Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. . |
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Skin Skin warm, dry, clean, and intact. No rashes or lesions noted. No upward curvature of the nails. |
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HEENT Mucous membranes pink and moist. No palpable lymph nodes. No palpable thyroid mass, trachea midline. |
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Cardiovascular Regular rate and rhythm. Pulses 3+ bilaterally. No edema. |
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Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. |
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Gastrointestinal BS active in all the four quadrants. Abdomen soft, nontender. No mass.No hepatosplenomegaly. |
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Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin. |
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Genitourinary Speculum exam performed, cervix w/o lesions. No visible discharge or blood in vaginal vault. Uterus anteverted, mobile, nontender. Adnexa nontender, palpable bilaterally Rectal exam reveals no mass, sphincter tone absent |
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Musculoskeletal Wheelchair bound. Deep tendon reflexes absent bilateral LE. |
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Neurological Motor and sensory exam absent BLE response. |
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Psychiatric Alert and oriented x4. Answers questions appropriately. Mood and judgement appropriate. |
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Lab Tests Beta quantitative HCG <5 mill/ML, urine pregnancy test negative Gonorrhea/chlamydia testing-negative Transvaginal US-anteverted uterus measures 64x20x34mm. Normal thickness endometrium 7mm. Early proliferative phase. Myometrium normal. Ovaries normal size and appearance bilaterally. Trace physiologic fluid in the cul-de-sac. Endometrial biopsy-no endometrial hyperplasia or atypia present Vaginal Wet Mount Ferritin level-11-307 mcg/L, TSH1.2 miU/L, Free T4 0.9-2.3 ng/dl, Hemoglobin/Hematocrit-13.0g/dl/39%
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Assessment |
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· Include at least three differential diagnoses-*****menorrhagia, missed abortion, STI, bacterial vaginitis, candida vaginitis · Provide rationale for each differential diagnosis · Final diagnosis-Menorrhagia · Pathophysiology of primary and rationale for choosing as final |
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Plan |
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· ******Include these: Insert hormonal IUD (brand name Mirena), follow up in one month for string check and status of cycle, · Medications · Non-pharmacological recommendations · Diagnostic tests · Patient education · Culture considerations · Health promotion-******include discuss timed toileting and when to self cath, monitor for autonomic dysreflexia monitor for skin breakdowb · Referrals · Follow up |