Use APA format and must include mia minimum of 2 Scholarly Citations.

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

Turn it in’ s Score must be less than 15% or will not be accepted for credit; it must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 15%. Copy-paste from websites or textbooks will not be accepted or tolerated and will receive a grade of 0 (zero) with no resubmissions allowed.

Must use the sample templates for your soap note. 

Guidelines for Focused SOAP Notes

· Label each section of the SOAP note (each body part and system).

· Do not use unnecessary words or complete sentences.

· Use Standard Abbreviations 

S: SUBJECTIVE DATA (information the patient/caregiver tells you).

Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes. 

History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter. 

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status. 

Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS. 

Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history. 

Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.

0: OBJECTIVE DATA (information you observe, assessment findings, lab results). 

Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data. 

Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data. 

NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.

Testing Results: Results of any diagnostic or lab testing ordered during that patient visit. 

A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)

 

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data. 

Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.

Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).

For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis. 

P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation. 

1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications. 

2. Additional diagnostic tests include EBP citations to support ordering additional tests

3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference. 

4. Referrals include citations to support a referral 

5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up. 

 

The purpose of this assignment is to analyze how an organization’s quality and improvement processes contribute to its risk management program.

This assignment builds on the Risk Management Program Analysis – Part One assignment you completed in Topic 1 of this course.

Assume that the sample risk management program you analyzed in Topic 1 was implemented and is now currently in use by your health care employer/organization. Further assume that your supervisor has asked you to create a high‐level summary brief of this new risk management program to share with a group of administrative personnel from a newly created community health organization in your state who has enlisted your organization’s assistance in developing their own risk management policies and procedures.

Compose a 1,250‐1,500 word summary brief that expands upon the elements you first addressed in the Topic 1 assignment. In this summary brief, address the following points regarding your health care organization and its risk management program:

1. Explain the role of your organization’s MIPPA-approved accreditation body (e.g., JC, ACR, IAC) in the evaluation of your institution’s quality improvement and risk management processes.
2. Describe the roles that different levels of administrative personnel play in healthcare ethics and establishing or sustaining employer/employee-focused organizational risk management strategies and operational policies.
3. Illustrate how your organization’s risk management and compliance programs support ethical standards, patient consent, and patient rights and responsibilities.
4. Explain the legal and ethical responsibilities health care professionals face in upholding risk management policies and administering safe health care at your organization.
5. Relate how your organization’s quality improvement processes support and contribute to its overall journey to excellence.

In addition to your textbook, you are required to support your analysis with a minimum of three peer‐reviewed references.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

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.

Benchmark Information

This benchmark assignment assesses the following programmatic competencies:

BS Health Sciences

3.3 Explain the ethical and legal responsibilities of health care professionals related to risk management assessment and policies.

Assignment is very simple. Doesn’t have to be a full page of information on each page just 5-7 bullet points on each page. Below I attached an example of a student who did their assignment on headaches that you can use to help you out.

For this project, you will complete a clinical case study analysis, research review, and PowerPoint video presentation about the pathophysiology of Chronic Pain OR Cancer-Related Pain OR Neuropathic Pain. (choose any of the three)

1. Your presentation should follow a case study SBAR format (situation, background, assessment, and recommendations).
2. You must include three (3) different medical-based evidence and/or research recommendations.
3. You must include at least three (3) scholarly sources in your overall presentation.

Your PowerPoint presentation should include the following slides:

• Introduction to the case or situation
• Background detail
• Clinical assessment
• Recommendations
• Application to future practice
• Reference slide: At least three (3) scholarly references supporting your ideas.

 

nd then reflect on the following prompt:

This video conjures many emotions, both as a nurse and a moral human being. Most of us entered/will enter the profession of nursing in response to a calling to care for our fellow human beings. For many of us, we believe with an urgent commitment that nursing is who we are, not simply what we do. We are guided by a moral compass that sets our life course based on knowing right from wrong, good from evil. 

While it is impossible for us to understand how the nurses in the concentration camps could be complicit in their role as ‘doers’ of euthanasia, it is curious how many of them came to believe that killing was a legitimate part of their caring role. These thoughts beg many questions, the answers for which will be reflective of your own beliefs and values system. Answer the following in your Forum post:

Do you think these nurses were complicit from the beginning, or did they slowly become involved over time until it became easier to cross the line? Once they did cross the line, how might a sense of power have overtaken their moral judgment? Perhaps they were indoctrinated to believe that the health of the public at large was more important than the health of the individual; yet how could they justify their actions to exploit the few for the benefit of the many? Were they simply following orders? Were they motivated by the thought of losing their job, or maybe even their life, if they refused? Could they have truly believed that they were simply relieving these children of their suffering and in so doing were being merciful in their actions?

In the context of your own nursing practice, why is this reflection activity important? Think about your own vulnerability to outside pressures and influences—would you speak up today if your moral position was threatened? Why or why not? Consider this from a position of power that you may or may not have. In today’s challenging healthcare environment, why is it important that we not only understand our moral position but that we also monitor our own response and the response of others?    

PermalinkReply◄ Researcher Misconduct
 

Now, write three to four 3 possible goals and objectives for this practicum experience. Ensure that they follow the SMART Strategy, as described in the Learning Resources. 

1. Goal:

a. Objective:

b. Objective:

c. Objective:

2. Goal:

a. Objective:

b. Objective:

c. Objective:

3. Goal:

a. Objective:

b. Objective:

c. Objective: