Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating a evidence-based plans of care.

Develop an academic clinical discharge summary note based on a hospital patient seen during clinical. The discharge summary note should include the following: ( Acute Care Hospital)

1. Reason for admission: Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis.

2. List of all procedures: Include all dates, significant findings, and any anesthetics and contrast used during procedures.

3. Complete list of consults during hospitalization: Include any providers or services consulted during stay.

4. Patient’s condition at discharge: Include a physical exam prior to discharge that documents that patient is stable at discharge and has safe disposition and transportation. What diagnostic criteria confirmed the discharge diagnosis?

5. Complete list of discharge medications: Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed.

6. Pending test results for follow up: Complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, and who is responsible for follow-up on final results.

7. Complete list of discharge instructions: Full list of directions regarding infection prevention, new medications, and returning to daily activities.

8. Complete list of discharge follow-ups: Full list of any therapies, treatments, referrals, consults, and follow-up appointments. What diagnostic criteria were needed after discharge?

9. Summary: What questions were raised during the hospital stay? Include all explanations and answers to these questions. What questions were raised that required further exploration? What kind of discharge planning did you need? Characterize your patient interaction activities.

10. Overall assessment: Identify health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes.

Incorporate 3-5 peer-reviewed articles in the assessment or plan. (Minimum 1000 words).

Don’t Forget to include all coding including ICD-10, CPT and all others.

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.

• Write a 2- to 3-page paper that addresses the following:
  
  • Explain the ethical and legal implications of the scenario you selected on all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family.
  • Describe strategies to address disclosure and nondisclosure as identified in the scenario you selected. Be sure to reference laws specific to your state.
  • Explain two strategies that you, as an advanced practice nurse, would use to guide your decision making in this scenario, including whether you would disclose your error. Be sure to justify your explanation. 
  • Explain the process of writing prescriptions, including strategies to minimize medication errors.
• For the Week 1 Assignment, you will explore the ethical and legal implications of the following scenario, and consider how to appropriately respond:

As a nurse practitioner, you prescribe medications for your patients. You make an error when prescribing medication to a 5-year-old patient. Rather than dosing him appropriately, you prescribe a dose suitable for an adult.  

  

Based on the information collected in the Research Method, formulate the Results section of your selected topic. Do not forget that your Results section needs to provide a visual (table, graphic, figure, etc.) and a narrative paragraph that helps your reader understand the information presented in the visual. Please do not interpret the results! 

 
 

Structure

 
 

6. Results

a. Take the sources identified in the Method

b. Simply present the Results in a narrative paragraph 

· Order: chronological order; importance; contribution, etc. 

· Do not interpret Results

· Do not analyze the Results

c. Add a visual aid (table, figure, graph, etc.)

 
 

Minimum five (5) references: studies (2016-2021)

Influence of Physical Exercise on Mental Health

Resource

Criterion 1: 

Criterion 2: 

Criterion 3: 

These three criteria will have to be related to each bibliography.

It can be in the form of a table, figure, graph, etc

 

1. Describe your response to the pain you have experienced. Explain and describe the pain you were experiencing. What were the effective methods used to deal with the pain? Describe pharmacological and non-pharmacological therapies used to relieve pain.
2. Did those around you understand the pain you were experiencing? Why or why not? How did their understanding or lack of understanding make you feel?
3. How could this experience with pain impact your response to a patient with pain?

The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in the previous week’s learning materials- APPENDICITIS. Review the SOAP Note Rubric. Use a case from the previous week’s discussion or patient from your video submission or clinical practicum experience (adding content as needed to represent abnormal findings). Submit your own note. Do not submit documentation from the patient’s record.

RUBRIC:

 

SOAP Note Rubric

[SOAP Note Rubric] – 100 PointsCriteriaExemplary
Exceeds ExpectationsAdvanced
Meets ExpectationsIntermediate
Needs ImprovementNovice
InadequateTotal Points

Subjective – 25%

Information about the patient (3 points)

• Name (initials only); age, and gender
• Source of information; note relationship to patient, if relevant
• Reliability of information

Chief Complaint (1 point)

History of Presenting Illness (8 points)

• Location
• Quality
• Quantity or severity
• Timing (onset, duration, frequency)
• Setting in which it occurs
• Factors that aggravate or relieve the symptoms
• Associated manifestations

Review of Focus System(s) (5 points)

Medications/Allergies (3 points)

History (5 points)

• Past Medical History
• Past Surgical History
• Family History
• Social History
• Health Maintenance Practices

Patient described in appropriate detail

Concise and clear chief complaint as described by patient

HPI includes all components with appropriate detail

Comprehensive review of focus system(s) includes pertinent negatives

Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance;
Allergies to medications and reaction noted

Comprehensive health history is appropriate to reason for visit and includes pertinent negatives

25 pointsPatient described in appropriate detail

Concise and clear chief complaint as described by patient

HPI missing minor detail

Comprehensive review of focus system(s)

Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction noted

Comprehensive health history is appropriate to reason for visit

22 points1 detail missed in patient description

Chief complaint as described by patient, may not be concise or clear

HPI missing 1 component or significant detail

Review of focus system missing 1-2 components

Medication history missing 1-2 components

Health history not appropriate for reason for visit or missing 1-2 components

19 points>2 details missed in patient description

Chief complaint not identified, concise, or clear

HPI missing >2 components and significant detail

Review of focus system(s) missing >3 components

Medication history missing >3 components

Health history missing >3 components

17 points25Objective – 30%

Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems (20 points)

Appropriate techniques of examination used to identify pertinent findings (10 points)Appropriate areas and systems included in physical assessment

Comprehensive techniques of observation, palpation, percussion, and auscultation noted including special assessments as appropriate

30 points

Missing 1 expected area of assessment

Appropriate techniques of examination used but special assessment technique missed

26 points

Missing 2 expected areas of assessment

One basic technique of examination missed

23 pointsMissing >3 expected areas of assessment

>2 techniques of examination missed

20 points30Assessment – 20%

Differential diagnoses are supported by subjective and objective findings (15 points)

Scholarly resources support differential diagnoses (5 points)Three differential diagnoses are supported by findings and include worst case scenario

Rationale for differential diagnoses provided by scholarly resources

20 pointsThree differential diagnoses include worst case scenario but one diagnosis may not be fully supported by findings

Rationale for differential diagnoses provided by scholarly resources

17 pointsDifferential diagnoses may or may not include worst case scenario and 2 differential diagnoses not supported by findings

Rationale for all differential diagnoses not provided by scholarly resources

15 points<3 differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst case scenario

Scholarly resources not provided or do not support differential diagnoses

13 points20Plan – 15%

Comprehensive plan to address likely differential diagnosis includes (9 points)

• Diagnostic testing
• Pharmacologic intervention
• Non-pharmacologic intervention
• Referrals
• Patient education
• Follow-up

Plan is supported by appropriate and current practice guidelines (6 points)Comprehensive plan includes all components

Appropriate and current guidelines cited

15 pointsPlan missing 1 of the identified components

Appropriate and current guidelines cited

13 pointsPlan missing 2 of the identified components

Guidelines are not current or appropriate for identified problem

12 pointsPlan missing >3 of the identified components

Guidelines for plan not cited

10 points15Documentation – 10%

Documentation follows SOAP template, is logical, and in correct format (10 points)Logical and systematic organization of data

Correct terminology, spelling, and grammar

Scholarly resources noted in correct APA format

10 pointsLogical and systematic organization of data

Terminology, spelling, grammar or format errors (1-3)

8 pointsMinor errors in organization of data

Terminology, spelling, grammar, or format errors (4-5)

7 pointsDisorganized flow of data

Terminology, spelling, grammar or format errors (>5)

6 points10Total Points100