Clinical documentation

Need help with my Health & Medical question – I’m studying for my class.

 

The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.

  1. Select a complex patient encounter that involves pediatric health issues.
  2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, routine physical exam (etc.)’ type of encounter. Please See attached for additional information. All requirements must be addressed.Must be in APA format

 

Unformatted Attachment Preview

1 Diagnostic and Clinical Reasoning Paper Assignment 80 Point Rubric Criterion Highly Proficient Points 15 Subjective Data Proficient 13 All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented and demonstrate consistent information across all aspects represented All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are appropriately documented and demonstrate consistent information across all aspects represented Points 15 Objective Data All elements of objective data are adeptly documented and demonstrate consistency relative to the 13 All elements of objective data are appropriately documented and demonstrate consistency relative to the Marginally Proficient 11 Approaching Proficiency 9 Not Proficient Not evident 7 0 All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are satisfactorily documented but do not demonstrate consistent information across all aspects represented 11 All elements of objective data are satisfactorily documented but do not demonstrate consistency All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are either not satisfactorily documented or do not demonstrate consistent information across all aspects represented 9 All elements of objective data are either not satisfactorily documented or do not demonstrate consistency All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented and do not demonstrate consistent information across all aspects represented 7 All elements of objective data are not satisfactorily documented and do not demonstrate consistency No elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are provided in the assignment 0 No elements of objective data are provided in the assignment Total Points 2 Assessment Plan information documented in the CC, HPI, PMH, and ROS information documented in the CC, HPI, PMH, and ROS Points 10 Assessment designations and other elements in this section are adeptly documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data 9 Assessment designations and other elements in this section are appropriately documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data Points 10 Elements of the plan are adeptly documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented 9 Elements of the plan are appropriately documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented relative to the information documented in the CC, HPI, PMH, and ROS 8 Assessment designations and other elements in this section are satisfactorily documented but do not demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data 8 Elements of the plan are satisfactorily documented but either do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across relative to the information documented in the CC, HPI, PMH, and ROS 7 Assessment designations and other elements in this section are either not satisfactorily documented or do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data 7 Elements of the plan are either not satisfactorily documented, or do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across all aspects represented relative to the information documented in the CC, HPI, PMH, and ROS 6 Assessment designations and other elements in this section are not satisfactorily documented and do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data 6 Elements of the plan are not satisfactorily documented, do not demonstrate application of current clinical practices for the identified assessment designations, and do not demonstrate congruence of information across 0 Assessment designations and other elements in this section are not provided in the assignment 0 Elements of a plan are not provided in the assignment 3 Points 10 Clinical Decision All elements of Making Clinical Decision Making (pathophysiology, pharm/alternate therapy, differential diagnoses, ethical/cultural concerns, and barriers) are adeptly documented and demonstrate congruence with information across all preceding sections (SOAP) of the assignment 9 All elements of Clinical Decision Making (pathophysiology, pharm/alternate therapy, differential diagnoses, ethical/cultural concerns, and barriers) are appropriately documented and demonstrate congruence with information across all preceding sections (SOAP) of the assignment Points 10 Evidence-based Elements of Practice (EBP) EBP(formulation of evidence support question, demonstration of the results of a scholarly search for EBP resources or CPGs, appraisal of the evidence located, analysis of the applicability of the EBP or CPG 9 Elements of EBP(formulation of evidence support question, demonstration of the results of a scholarly search for EBP resources or CPGs, appraisal of the evidence located, analysis of the applicability of the EBP or CPG all aspects represented 8 All elements of Clinical Decision Making (pathophysiology, pharm/alternate therapy, differential diagnoses, ethical/cultural concerns, and barriers) are satisfactorily documented but do not demonstrate congruence with information across all preceding sections (SOAP) of the assignment 8 Elements of EBP(formulation of evidence support question, demonstration of the results of a scholarly search for EBP resources or CPGs, appraisal of the evidence located, analysis of the applicability of the EBP or CPG 7 All elements of Clinical Decision Making (pathophysiology, pharm/alternate therapy, differential diagnoses, ethical/cultural concerns, and barriers) are either not satisfactorily documented or do not demonstrate congruence with information across all preceding sections (SOAP) of the assignment 7 Elements of EBP(formulation of evidence support question, demonstration of the results of a scholarly search for EBP resources or CPGs, appraisal of the evidence located, analysis of the applicability of the EBP or CPG all aspects represented 6 All elements of Clinical Decision Making (pathophysiology, pharm/alternate therapy, differential diagnoses, ethical/cultural concerns, and barriers) are not satisfactorily documented and do not demonstrate congruence with information across all preceding sections (SOAP) of the assignment 6 Elements of EBP(formulation of evidence support question, demonstration of the results of a scholarly search for EBP resources or CPGs, appraisal of the evidence located, analysis of the applicability of the EBP or CPG 0 Elements of clinical decision making are not provided in the assignment 0 No elements of evidence-based practice are provided in the assignment 4 guidelines to this encounter, analysis of patient care values to EBP or CPGs presented to them during your encounter) are adeptly discussed and demonstrate congruence with information across all preceding sections (SOAP and Clinical Decision Making) of the assignment Points 5 SelfReflective Reflection/Critique discussions of decision making and advanced practice practitioner role analysis are adeptly articulated and logically flow from the discussions in the preceding sections (SOAP, Clinical Decision Making, and EBP) of the assignment Points 5 guidelines to this encounter, analysis of patient care values to EBP or CPGs presented to them during your encounter) are appropriately discussed and demonstrate congruence with information across all preceding sections (SOAP and Clinical Decision Making) of the assignment guidelines to this encounter, analysis of patient care values to EBP or CPGs presented to them during your encounter) are satisfactorily discussed but do not demonstrate congruence with information across all preceding sections (SOAP and Clinical Decision Making) of the assignment 4.5 Reflective discussions of decision making and advanced practice practitioner role analysis are appropriately articulated and logically flow from the discussions in the preceding sections (SOAP, Clinical Decision Making, and EBP) of the assignment 4 Reflective discussions of decision making and advanced practice practitioner role analysis are satisfactorily articulated but do not logically flow from the discussions in the preceding sections (SOAP, Clinical Decision Making, and EBP) of the assignment 4 4.5 guidelines to this encounter, analysis of patient care values to EBP or CPGs presented to them during your encounter) are either not satisfactorily discussed or do not demonstrate congruence with information across all preceding sections (SOAP and Clinical Decision Making) of the assignment 3.5 Reflective discussions of decision making and advanced practice practitioner role analysis are either not satisfactorily articulated or do not logically flow from the discussions in the preceding sections (SOAP, Clinical Decision Making, and EBP) of the assignment 3.5 guidelines to this encounter, analysis of patient care values to EBP or CPGs presented to them during your encounter) are not satisfactorily discussed and do not demonstrate congruence with information across all preceding sections (SOAP and Clinical Decision Making) of the assignment 3 Reflective discussions of decision making and advanced practice practitioner role analysis are not satisfactorily articulated and do not logically flow from the discussions in the preceding sections (SOAP, Clinical Decision Making, and EBP) of the assignment 3 0 No reflective discussions are provided in the assignment 0 5 Professional Communication The discussions and exploration of thoughts are adeptly provided and demonstrate sound grammatical construction without readily detectable errors in application of APA style guidelines The discussions and exploration of thoughts are appropriately provided and demonstrate sound grammatical construction with only minor detectable errors in application of APA style guidelines The discussions and exploration of thoughts are satisfactorily provided but either do not demonstrate sound grammatical construction or include several readily detectable errors in application of APA style guidelines The discussions and exploration of thoughts are either not satisfactorily provided, or do not demonstrate sound grammatical construction, or include several readily detectable errors in application of APA style guidelines The discussions and exploration of thoughts are not satisfactorily provided, do not demonstrate sound grammatical construction, and include several readily detectable errors in application of APA style guidelines No discussions or exploration of thoughts are provided in the submission Total Score: XX/80 The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases. 1. Select a complex patient encounter that involves women health issues. 2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter. Please See attached for additional information. All requirements must be addressed.Must be in APA format 3. Please look over comments and perhaps consult other examples of diagnostic reasoning papers that will help you write a more succinct, clear paper. 4. Please make the paper flow logically so that the reader can clearly see the progression. Consult other papers if you have access to examples. 5. Just make your working and final diagnoses clear and indicate what made you choose the tests that you chose and the treatments you chose. 6. There are several distracting grammar errors throughout this paper. 7. Usually this evaluation would include an ROS that addresses whether there is any vaginal discharge, itching or pain present. 8. The objective documentation of the vaginal GU exam is incomplete – there is no notation of the presence and position of the cervix and uterus. In addition there is not documentation of the bi-manual exam of the ovaries and whether they were able to be palpated or not. There is also no documentation of any discharge, irritation or the more detailed appearance of the vaginal and cervix. Typically there is documentation of whether or not there is cervical motion tenderness as well. 9. This section should include a list of all of your working diagnoses that are addressed through your diagnostic workup. You should have at least four differential diagnosis and then your final diagnosis. This seems to be out of sequence in the paper with the table. However the table addition showing your working diagnoses was a fortunate addition to your paper. 10. In reviewing your plan I do not see the diagnosis for which you are treating this patient. In fact I am not sure where your plan begins. It appears that it is under the heading “therapeutic.” What diagnosis are you treating with the estradiol? “Progesterone will also be given to treat some problems with the uterus.” What does this mean? What do you mean by “some problems.” This should be concisely articulated instead of your statement so that the reader knows exactly what you are referring to. Your differentials and treated diagnosis should be listed out clearly and designated clearly with each one identified with the corresponding workup and reasoning. It appears that this is out of sequence in your paper and appears under the heading “priority diagnosis discussion.” My suggestion is to keep your sections of your paper in the order of the rubric. 11. The clinical decision making heading should list why the treatments chosen for the diagnosis were chosen and how you came to these conclusions. Unfortunately your paper under this heading goes straight into pathophysiology – but is not flowing and explaining the basis for clinical decision making. Parts of the plan appear to be in this section with the pharmacology entries. 12. Your paper reflects evidence based practice with plenty of documentation on the treatments for the differential diagnosis – however I can’t tell the exact diagnosis you are treating as it is not clearly articulated with the accompanying clear articulation of the corresponding treatment. My suggest is that you format your papers with more clarity for your final diagnosis and then list our the rest of your differentials. When designating your final diagnosis I suggest you indicate it clearly along with the corresponding plan. 13. 1 Diagnostic and Clinical Reasoning Paper Assignment The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases. 1. Select a patient encounter from a complex diagnosis 2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter. You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper. 3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual. Below is the overview of the required elements for this assignment: *Title Page (Page 1): Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date. *Subjective (Start of Page 2): Follow APA guidelines for running head on page 2 and subsequent pages. CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased. HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary] PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. 2 Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, and routes of administration. Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. Click on the link below to explore the CDC’s information on the ‘social determinants of health’. https://www.cdc.gov/socialdeterminants/ Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Health Maintenance/Promotion: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Click on the link below to access information about current guidelines. https://www.uspreventiveservicestaskforce.org/ Review of Systems (ROS): this is to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness. You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/categories applicable to your patient’s chief complaint. General: May include if patient has had a fever, chills, fatigue, malaise, etc. Skin: HEENT: head, eyes, ears, nose and throat Neck: CV: cardiovascular Lungs: GI: gastrointestinal GU: genito-urinary PV: peripheral vascular MSK: musculoskeletal 3 Neuro: neurological Endo: endocrine Psych: *Objective: Physical Examination (PE): either limited for a focused exam or more extensive for a complete history and physical assessment. This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e.GYN, Rectal, Abd, etc.) you may omit other assessments. All SOAP notes howe …
Purchase answer to see full attachment

Place this order or similar order and get an amazing discount. USE Discount code “GET20” for 20% discount