Focused SOAP Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. 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 three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

To Prepare

• Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
• 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:

• Dress professionally with a lab coat and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• 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 their 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. Also 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 again? 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.

  

Do you believe that the advanced practice nurse can bridge the nurse-patient cultural gap?

Post should be a minimum of 350 words, scholarly written, APA formatted, and referenced.  A minimum of 4 references are required (other than your text). 

Introduction

The growing diversity in the United States has played a major role in movement to cultural competency in healthcare.  As of 2016, there were nearly 44 million immigrants living in the US which is four times what it was in 1965. Our ever changing ethnic population brings many challenges for healthcare workers to provide care in this multicultural, multiethnic, and economically diverse population.

Global health is focused on human health issues that transcend borders. In an attempt to improve health and achieve equality in health care worldwide an emphasis on transnational health issues involve research and practice as well as interdisciplinary collaboration to attain solutions.  Increasingly we are living in a globalized world where health problems can ravage groups and create worldwide political instability. Due to this, the UN conducted a summit to discuss the growing global concern of chronic diseases or Non-communicable diseases. Please refer to the following link to review the summary report of this discussion:

UN High Level Meeting on NCDs. Retrieved from:
http://www.who.int/nmh/events/moscow_ncds_2011/round_tables_summary.pdf

 

The Role of the Advanced Practice Nurse

The National League for Nursing has identified the role of nursing in global diversity as a critical priority and the advanced practice nurse will be providing care to a very diverse global population of patients. Bridging this cultural gap is a major challenge of the APN.  Dayer-Berenson (2014) suggests that in order to achieve this we should follow the mnemonic of ASKED which is awareness, skill, knowledge, encounters, and desire.

We need to perform a self-assessment to become aware of personal biases and prejudices toward other culture groups. Cultural skill is the ability to conduct a cultural assessment to collect relevant cultural data concerning the client’s presenting problem as well as conducting a culturally sensitive physical examination. As advanced practice nurses we must obtain a sound educational base about culturally diverse groups. By engaging in cultural interactions or encounters with clients from culturally diverse backgrounds help modify existing beliefs and prevents stereotyping.  And finally the cultural desire is the motivation to want to engage in the process of becoming culturally aware, culturally knowledgeable, and culturally skillful and to seek cultural encounters.

APNs are in key positions to improve healthcare for patients from various cultures by overcoming barriers and reducing disparities. By practicing evidence based care to treat diseases as well as providing much needed research of ethnic and racial minorities the APN has the ability to increase the quality of healthcare delivery for this population.

 Please complete the following steps for your initial discussion post:

• Choose one leadership, management or organizational theory from your textbook and complete a library search for a peer-reviewed journal article that integrates the chosen theory with a nursing management/leadership topic.
• Present the article and discuss the theory used, the benefits of utilizing theory in this management/leadership article, and any weaknesses you identify with using the theory.
• Discuss how application of leadership theoretical frameworks and models can benefit nurse leaders personally and advance the nursing profession as a whole.
• Responses should be at least 500 words, integrate key concepts from the weekly readings and include specific examples of how the concepts can be applied to your work environment.
• Attach a copy of the article to this discussion forum.
• Be sure to supplement your discussion with personal and professional experiences.

Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with citations and references in APA format.  
Please review the rubric to ensure that your response meets the criteria. 

 

Select a care environment where advanced practice registered nurses (APRNs) may practice. Some examples to choose from may include:

• Rural health clinic
• Emergency department
• Urgency care
• Community health center
• Family practice
• Pediatric Clinic

Using the conditions listed in Box 11.1 in the Joel textbook, identify and discuss two different conditions that may have a significant impact on revenue in the care setting. Describe how these conditions might affect how APNs provide care in these settings?

• Length: A minimum of 300 words, not including references
• Citations: At least one high-level scholarly reference in APA from within the last 5 years

  

Week 4 | Part 4: Research Analysis

I have identified one topic of interest for further study. I have researched and identified one peer-reviewed research article focused on this topic and have analyzed this article.  The results of these efforts are shared below.

Directions: Complete Step 1 by using the table and subsequent space below identify and analyze the research article you have selected. Complete Step 2 by summarizing in 2-3 paragraphs the results of your analysis using the space identified.

  

Step 1: Research Analysis 

Complete the table below

  

Topic of Interest:

 

Research Article: Include full citation in   APA format, as well as link or search details (such as DOI)

 

Professional Practice Use: 

One or more professional practice uses of the theories/concepts   presented in the article

 

Research Analysis   Matrix 

Add more rows if   necessary

Strengths   of the Research

Limitations   of the Research

Relevancy   to Topic of Interest

Notes