soap note

apa style

no plagiarism or AI

Identify the basic concepts of the electronic health record (EHR), mobile health, and telehealth systems in enabling patient care. Explain the impact of health information exchange, interoperability, and integration on the EHR, mobile health, and telehealth systems to provide the best outcomes for patient care. Within your scope of practice, which of these information and communication technologies do you use and how are they used?

Initial discussion question posts should be a minimum of 200 words and include at least two references cited using APA format. Responses to peers or faculty should be 100-150 words and include one reference. Refer to “RN-BSN Discussion Question Rubric” and “RN-BSN Participation Rubric,” located in Class Resources, to understand the expectations for initial discussion question posts and participation posts, respectively. 

Review the scenario below.

Carol, a nurse on a busy medical-surgical unit, is precepting Henry, a nursing student. Carol opens Mr. Smith’s chart in the electronic health record (EHR) to document his assessment. She must step away from the computer to assist with an emergency with another patient. Carol asks Henry to continue charting the assessment in Mr. Smith’s chart while she is gone. Henry completes the charting for Mr. Smith and then opens the charts of other patients on the unit to see why they have been admitted.

Carol returns to the computer with Henry. Mr. Smith had requested a printout of his medications. Carol clicks print for the medication list but did not notice that Henry had opened another patient’s chart. Carol and Henry leave the computer to find the printer for Mr. Smith’s medication list.

George, another nurse on the floor, sees that the EHR is logged in and is in a hurry. He switches to his patient’s chart and documents his patient’s vital signs and administration of a medication. He does not sign the computer off but leaves to go administer the medication.

Samuel, a social worker from another unit, comes by to see Mr. Smith, who is his neighbor. Mr. Smith is sleeping, and the EHR is open on the computer. Samuel is curious about why Mr. Smith is in the hospital, so he starts to read the chart.

Carol and Henry are unable to find the medication list for Mr. Smith but did find a print-out of a medication list for another patient on the unit. They return to the computer to re-print the medication list where they find Samuel reviewing Mr. Smith’s chart.

Respond to the following prompts:

• Evaluate the professional responsibilities for the ethical use of health care informatics technology.
• Discuss the ethical challenges the nurse encountered in this scenario and the principles that were violated.
• Describe how you would handle this in your own practice or describe one thing that could have been done differently.

Initial discussion question posts should be a minimum of 200 words and include at least two references cited using APA format. Responses to peers or faculty should be 100-150 words and include one reference. Refer to “RN-BSN Discussion Question Rubric” and “RN-BSN Participation Rubric,” located in Class Resources, to understand the expectations for initial discussion question posts and participation posts, respectively.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 9.4

This assignment will focus on introducing you to the question of human dignity and, in particular, the Christian perspective of the intrinsic worth and value of each person. You will have the opportunity to integrate this insight with scientific and philosophical approaches that inform judgements made in health care and contrast it with secular approaches to human value and worth. The logic of human rights will be made explicit as you engage with different concepts of “moral status.”

Based on your reading of the “Case Study: Fetal Abnormality” and topic Resources, complete the “Moral Status: Case Analysis” document, in which you will analyze the case study in relation to the following:

• Christian view of the nature of human persons, theory of moral status, intrinsic human value, and dignity
• Theory or theories used by individuals in the case to determine the moral status
• How each theory used determines or influences recommendations for action
• Moral status theory personal response
• Integration of knowledge in health care (theories, multiple ways of knowing, evidence) and knowledge from other disciplines inform and support current or future professional health care practices and judgements

Support your response using only Chapter 2 from the textbook Practicing Dignity: An Introduction to Christian Values and Decision-Making in Health Care and the Topic 2 Resource “The Image of God, Bioethics, and Persons With Profound Intellectual Disabilities.”

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. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.