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4 REFERENCES 

ZERO PLAGIARISM

Psychiatric 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 SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care. 

For this Assignment, you will document information about a patient that you examined during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

 

• Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
  Please Note:
  • All SOAP notes must be signed, and each page must be initialed by your Preceptor.
    Note: Electronic signatures are not accepted.
  • When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
  • You must submit your SOAP note using SafeAssign.
    Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
• Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentation

• Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment? 
  • Assessment: Discuss patient mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy? 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. Be sure to include at least one health promotion activity and one patient education strategy.
  • Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

By Day 7 o

  

Part 1

           In 2008, the Institute of Medicine partnered with the Robert Wood Johnson Foundation to not only assess, but also respond to the need of nursing profession transformation. Their report titled the “Future of Nursing: Leading Change, Advancing Health” set a path for advancing the responsibilities or role of nurses in the United States. The report proposes eight recommendations: a nurse ought to practice to the full extent of his or her education and training; and a nurse should attain higher levels of training plus education through improved educational system that enhances seamless educational progression. Thirdly, nurses ought to be full partners with other healthcare practitioners in redesigning the United States healthcare practice. Finally, there is need for better data collection plus improved information infrastructure for effective workforce planning as well as policy making (RWJF & IOM, 2010).   

           Since 2010, various states across United States have established coalition to help realize the recommendations of the Institute of Medicine and the Robert Wood Johnson Foundation report. One such action coalition is the Florida Action Coalition. This coalition, headquartered at the Florida Nursing Working Center, conducted a statewide study whose findings were used as a foundation for a training program of promoting nursing leadership. The coalition also established a program for emerging nurse leaders to provide a 90 day learning experience through group and individual coaching, online courses as well as webinars. The Florida Action Coalition’s website features graduates who are linked with new organizations searching for nurse leaders join their boards. So far, 18 out of 26 graduates of the initiative are working on policy making boards and other agencies. Finally, the coalition has partnered with the Florida Blue- a component of the Blue Cross and Blue Shield Association-to strengthen its ability to not only sustain itself, but also for statewide health improvement (FAC, 2018).   

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Part 2

you did a good job in researching and developing your response.  You stated, ” the coalition has partnered with the Florida Blue- a component of the Blue Cross and Blue Shield Association-to strengthen its ability to not only sustain itself, but also for statewide health improvement.”  What initiatives has Florida developed to help sustain itself and to improve health statewide?  

Numerical data, measured in quantitative terms, reveal trends and patterns over time. For, example testing a new fall-prevention program within your hospital would require you to obtain a baseline fall rate before the program and then again after implementation of the program. Statistically, you could compare rate of falls before the new program with the rate of falls after the new program.

Describe another example of quantitative research design. How do quantitative research designs improve quality of care and health outcomes?

Post 3: In the graphic novel Maus, how does Art Spiegelman demonstrate “the depth and subtlety that we have come to expect of traditional novels and extended nonfictional texts”? (See the definition of graphic novel in this week’s Terms lecture.) Comment on Spiegelman’s success. Be sure to quote, cite, and reference from the text(s) using appropriate APA format. Your post must be at least 250 words.
 

    

Rubric

Description: Utilize Case Study found in the Description of this Assignment as a hyper link in Module 3 Assignments.

Identifying Data and Rationale 

1 (6.66666%) 

Student identifies CLINICALLY SIGNIFICANT data from the chief complaint, vital signs, and nursing assessment AND explains WHY each piece of data identified is clinically significant. Faculty may assign partial points for missing parts.

Lab/Diagnostic Identification

1 (6.66666%) 

Student identifies lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse AND WHY. Faculty may assign partial points for missing parts.

Primary concern and Pathophysiology/Cause

2 (13.33333%) 

Student identifies the PRIMARY problem that the client is presenting with AND the underlying Pathophysiology/Cause of this concern. Faculty may assign partial points for missing parts.

Nursing Priority

1 (6.66666%) 

Student identifies what nursing priority will guide their care (example: Maslow’s).

Nursing Interventions

2 (13.33333%) 

Student lists FOUR interventions with Rationale and Expected Outcome based on the identified nursing priority. Faculty may assign partial points for missing parts.

#7 Rational and Expected Outcome

2 (13.33333%) 

Student lists the rationale AND expected outcome for EACH nursing intervention/order listed in #7. Faculty may assign partial points for missing parts.

Body systems, Complications, and Assessments

3 (20.00%) 

Student fully answers ALL of the following 1. What body system(s) will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern? AND 2. What is the worst possible complication to anticipate? (start with A-B-C priorities) AND 3. What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops. Faculty may assign partial points for missing parts.

Client Experience

2 (13.33333%) 

Student answers ALL of the following: 1. What is the patient likely experiencing/feeling right now in this situation AND 2. What can you do to engage yourself with this patient’s experience, and show that they matter to you as a person? Faculty may assign partial points for missing parts.

Grammar & Spelling

1 (6.66666%) 

Few grammar and spelling errors that do not detract the reader from the message.