Soap Note 2 Chronic Conditions

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Late Assignment Policy

Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions

 Follow the MRU Soap Note Rubric as a guide:

Grading Rubric 

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1)      Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2)      Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3)      Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a)      Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b)      Pertinent positives and negatives must be documented for each relevant system.

c)        Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4)      Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5)      Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6)      Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7)      Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

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Assessment Instructions 

Your manager asked you to prepare an article for a community newsletter for a local retirement village. The editor wants you to talk about the laws, policies, and choices surrounding end-of-life health care decisions

Preparation 

Search the Capella library and the Internet for scholarly and professional peer-reviewed articles on end-of-life care. You will need at least three articles to use as support for your work on this assessment.

Directions

Write an article of 750–1,000 words (3–4 pages) that discusses the laws, policies, and choices surrounding end-of-life health care decisions. Address the following in your article: 

• Describe the role of the nurse in end-of-life decision making with patients and their families.
• Explain the legislation that generated end-of-life health care policies. Was the legislation an outcome of a specific medical case?
• Identify the primary policies regarding current health care practices related to end-of-life health care decisions. How to these policies affect treatment decisions?
• Explain the effect of end-of-life regulations and controls on patient outcomes. What effect does this have on the nurse-patient relationship?
• Describe the ethical considerations that have influenced policy decisions in regard to end-of-life decisions.

Additional Requirements

Your article should meet the following requirements:

• Written communication: Written communication should be free of errors that detract from the overall message.
• References: Cite a minimum of three resources; a majority of these should be peer-reviewed sources. Your reference list should be appropriate to the body of literature available on this topic that has been published in the past 5 years.
• APA format: Resources and citations should be formatted according to current APA style and formatting.
• Length: 750–1,000 words or 3–4 typed, double-spaced pages, excluding title page and reference page. Use Microsoft Word to complete the assessment.
• Font and font size: Times New Roman, 12-point.

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• Assume that you are leading a staff development meeting on regulation for nursing practice at your healthcare organization or agency.
• Review the NCSBN and ANA websites to prepare for your presentation.

The Assignment: (9- to 10-slide PowerPoint presentation)

Develop a 9- to 10-slide PowerPoint Presentation that addresses the following:

• Describe the differences between a board of nursing and a professional nurse association.
• Describe the geographic distribution, academic credentials, practice positions, and licensure status of members of the board for your specific region/area.
  • Who is on the board?
  • How does one become a member of the board?
• Describe at least one federal regulation for healthcare.
  • How does this regulation influence delivery, cost, and access to healthcare (e.g., CMS, OSHA, and EPA)?
  • Has there been any change to the regulation within the past 5 years? Explain.
• Describe at least one state regulation related to general nurse scope of practice.
  • How does this regulation influence the nurse’s role?
  • How does this regulation influence delivery, cost, and access to healthcare?
• Describe at least one state regulation related to Advanced Practice Registered Nurses (APRNs).
  • How does this regulation influence the nurse’s role?
  • How does this regulation influence delivery, cost, and access to healthcare?

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Throughout history, technological advancements have appeared for one purpose before finding applications elsewhere that lead to spikes in its usage and development. The internet, for example, was originally developed to share research before becoming a staple of work and entertainment. But technology—new and repurposed—will undoubtedly continue to be a driver of healthcare information. Informaticists often stay tuned to trends to monitor what the next new technology will be or how the next new idea for applying existing technology can benefit outcomes.

In this Discussion, you will reflect on your healthcare organization’s use of technology and offer a technology trend you observe in your environment.

To Prepare:

• Reflect on the Resources related to digital information tools and technologies.
• Consider your healthcare organization’s use of healthcare technologies to manage and distribute information.
• Reflect on current and potential future trends, such as use of social media and mobile applications/telehealth, Internet of Things (IoT)-enabled asset tracking, or expert systems/artificial intelligence, and how they may impact nursing practice and healthcare delivery. 

Post a brief description of general healthcare technology trends, particularly related to data/information you have observed in use in your healthcare organization or nursing practice. Describe any potential challenges or risks that may be inherent in the technologies associated with these trends you described. Then, describe at least one potential benefit and one potential risk associated with data safety, legislation, and patient care for the technologies you described. Next, explain which healthcare technology trends you believe are most promising for impacting healthcare technology in nursing practice and explain why. Describe whether this promise will contribute to improvements in patient care outcomes, efficiencies, or data management. Be specific and provide examples.

References:

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

• Chapter 14, “The Electronic Health Record and Clinical Informatics” (pp. 267–287)
• Chapter 15, “Informatics Tools to Promote Patient Safety and Quality Outcomes” (pp. 293–317)
• Chapter 16, “Patient Engagement and Connected Health” (pp. 323–338)
• Chapter 17, “Using Informatics to Promote Community/Population Health” (pp. 341–355)
• Chapter 18, “Telenursing and Remote Access Telehealth” (pp. 359–388)

Rao-Gupta, S., Kruger, D. Leak, L. D., Tieman, L. A., & Manworren, R. C. B. (2018). Leveraging interactive patient care technology to Improve pain management engagement. Pain Management Nursing, 19(3), 212–221. doi:10.1016/j.pmn.2017.11.002

Skiba, D. (2017). Evaluation tools to appraise social media and mobile applications. Informatics, 4(3), 32–40. doi:10.3390/informatics4030032

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Identify a quality improvement opportunity in your organization or practice. In a 1,250-1,500 word paper, describe the problem or issue and propose a quality improvement initiative based on evidence-based practice. Apply “The Road to Evidence-Based Practice” process, illustrated in Chapter 4 of your textbook, to create your proposal.

Include the following:

1. Provide an overview of the problem and the setting in which the problem or issue occurs.
2. Explain why a quality improvement initiative is needed in this area and the expected outcome.
3. Discuss how the results of previous research demonstrate support for the quality improvement initiative and its projected outcomes. Include a minimum of three peer-reviewed sources published within the last 5 years, not included in the course materials or textbook, that establish evidence in support of the quality improvement proposed.
4. Discuss steps necessary to implement the quality improvement initiative. Provide evidence and rationale to support your answer.
5. Explain how the quality improvement initiative will be evaluated to determine whether there was improvement.
6. Support your explanation by identifying the variables, hypothesis test, and statistical test that you would need to prove that the quality improvement initiative succeeded.

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. Refer to the LopesWrite Technical Support articles for assistance.

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