soap note pt 2
review by rubric and add references
review by rubric and add references
Describing, Diagnosing, & Treatment of Skin, Eye, & Ear Disorders
Please answer the following questions:
Submission Instructions:
The purpose of this assignment is to showcase the volunteer site you have secured for this course.
Create a 5-7-slide PowerPoint presentation that includes the following information. Be creative in how you showcase your volunteer site and include graphics, such as the company logo, examples from the company’s social media presence, or photographs of the company’s influence and leadership, etc.
Volunteer Site Contact Information
Background Information of Volunteer Site
Duties, Responsibilities, and Outcomes of Volunteer Experience
General Requirements
You are required to include speaker notes in the Notes section of the slides.
Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style.
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 not required to submit this assignment to LopesWrite.
The Centers for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of National Quality Forum (NQF) of “never events.” Meaning, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurred while a patient was under the care of a healthcare professional.
follow all directions
Description – Deliverable Length: 6–8 slides with clear and concise speaker notes.
NOTE: Cite at least 2 scholarly references published within the last 5 years.
As the manager of the CTU Health Care Information Systems Department, you realize the need for seamless integration among all operating systems of the departments within the healthcare organization (HCO). Discuss the importance of electronic health record (EHR) conceptual framework integration and achieving interoperability.
Prepare a PowerPoint presentation for the stakeholders of the different departments that expresses the importance of the interoperability of all computing systems within the HCO. In this presentation, you should address the ramifications of the lack of integration of the information systems among the departments.
Note: Use APA style 7th edition, and cite at least 2 scholarly references published within the last 5 years.
Primary Task Response: Within the Discussion Board area, write 400–600 words that respond to the following questions with your thoughts, ideas, and comments. This will be the foundation for future discussions by your classmates. Be substantive and clear, and use examples to reinforce your ideas.
As the manager of the CTU Health Care Information Systems Department, you recognize that change management is critical to the success of the implementation of the electronic health record (EHR) or electronic medical record (EMR). You also recognize that change management requires cultivating and managing realistic expectations of all of the departments involved when evaluating health records, including federal, state, and ethical guidelines.
For this assignment, you must explain how you would guide the change process among team members and departments. Consider the following questions:
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up
SOAP Note RubricSOAP Note RubricCriteriaRatingsPts
Demographics
1 to >0.8 pts
Begins with patient initials, age, race, ethnicity and gender (5 demographics)
0.8 to >0.25 pts
Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)
0.25 to >0 pts
Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)
0 pts
Missing criteria and/or submission.
/ 1 pts
Chief Complaint (Reason for seeking health care)
4 to >3 pts
Includes a direct quote from patient about presenting problem
3 to >2 pts
Includes a direct quote from patient and other unrelated information
2 to >0 pts
Includes information but information is NOT a direct quote
0 pts
Missing criteria and/or submission.
/ 4 pts
History of the Present Illness (HPI)
5 to >3 pts
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
3 to >2 pts
Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
2 to >0 pts
Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
0 pts
Missing criteria and/or submission.
/ 5 pts
Allergies
2 to >1.5 pts
Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
1.5 to >1 pts
If allergies are present, students lists type Drug, environmental factor, herbal, food, latex name and includes severity of allergy OR description of allergy
1 to >0 pts
If allergies are present, students lists only the type of allergy name
0 pts
Missing criteria and/or submission.
/ 2 pts
Review of Systems (ROS)
15 to >8 pts
Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”
8 to >3 pts
Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits” and “denies”
3 to >0 pts
Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits” and “denies”
0 pts
Missing criteria and/or submission.
/ 15 pts
Vital Signs
2 to >1.5 pts
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
1.5 to >1 pts
Includes 7 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
1 to >0 pts
Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
0 pts
Missing criteria and/or submission.
/ 2 pts
Labs
2 to >1.5 pts
Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.
1.5 to >1 pts
Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.
1 to >0 pts
Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values.
0 pts
Missing criteria and/or submission.
/ 2 pts
Medications
4 to >2 pts
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)
2 to >1 pts
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency)
1 to >0 pts
Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)
0 pts
Missing criteria and/or submission.
/ 4 pts
Past Medical History
3 to >2 pts
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
2 to >1 pts
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current
1 to >0 pts
Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current
0 pts
Missing criteria and/or submission.
/ 3 pts
Past Surgical History
3 to >2 pts
Includes, for each surgical procedure, the year of procedure and the indication for the procedure
2 to >1 pts
Includes, for each surgical procedure, the year of procedure OR indication of the procedure
1 to >0 pts
Includes, for each surgical procedure but not the year of procedure or indication of the procedure
0 pts
Missing criteria and/or submission.
/ 3 pts
Family History
3 to >2 pts
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
2 to >1 pts
Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
1 to >0 pts
Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
0 pts
Missing criteria and/or submission.
/ 3 pts
Social History
3 to >2 pts
Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
2 to >1 pts
Includes 10 of the 11 required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
1 to >0 pts
Includes 9 or less of the required information.
0 pts
Missing criteria and/or submission.
/ 3 pts
Health Maintenance / Screenings
3 to >2 pts
Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests
2 to >1 pts
Includes a partial assessment of immunization status and health maintenance needs, missing some key components. Includes an assessment of at least 4 screening tests
1 to >0 pts
Includes minimal assessment of immunization status and health maintenance needs, lacking detail. Includes an assessment of at least 3 screening tests
0 pts
Missing criteria and/or submission.
/ 3 pts
Physical Examination
15 to >8 pts
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint
8 to >3 pts
Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint
3 to >0 pts
Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint
0 pts
Missing criteria and/or submission.
/ 15 pts
Diagnosis
5 to >3 pts
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)
3 to >1 pts
Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority
1 to >0 pts
Includes 1 differential diagnosis for the principal diagnosis
0 pts
Missing criteria and/or submission.
/ 5 pts
Differential Diagnosis
5 to >3 pts
Includes at least 3 differential diagnoses for the principal diagnosis
3 to >1 pts
Includes at least 2 differential diagnoses for the principal diagnosis
1 to >0 pts
Includes at least 1 differential diagnoses for the principal diagnosis
0 pts
Missing criteria and/or submission.
/ 5 pts
ICD 10 Coding
3 to >2 pts
Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit
2 to >1 pts
Correctly includes most ICD-10 codes relevant to the diagnoses addressed at the visit
1 to >0 pts
Includes some ICD-10 codes relevant to the diagnoses addressed at the visit
0 pts
Missing criteria and/or submission.
/ 3 pts
Pharmacologic treatment plan
5 to >3 pts
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
3 to >1 pts
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the required following 7: the drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
1 to >0 pts
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes less than 4 of the information:
0 pts
Missing criteria and/or submission.
/ 5 pts
Diagnostic / Lab Testing
3 to >2 pts
Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
2 to >1 pts
Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time”
1 to >0 pts
Includes appropriate diagnostic testing less than 50% of the time.
0 pts
Missing criteria and/or submission.
/ 3 pts
Education
3 to >2 pts
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
2 to >1 pts
Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives.
1 to >0 pts
Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives
0 pts
Missing criteria and/or submission.
/ 3 pts
Anticipatory Guidance
3 to >2 pts
Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))
2 to >1 pts
Includes at least 2 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipator guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))
1 to >0 pts
Includes at least 1 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e. screening))
0 pts
Missing criteria and/or submission.
/ 3 pts
Follow Up Plan
2 to >1 pts
Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)
1 to >0 pts
Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months)
0 pts
Missing criteria and/or submission.
/ 2 pts
Prescription
3 to >2 pts
Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials
2 to >1 pts
Prescription includes most required components, but is missing 1-2 elements such as quantity to be dispensed or refills
1 to >0 pts
Prescription is missing 3 or more required components such as patient information, date, or provider’s signature
0 pts
Missing criteria and/or submission.
/ 3 pts
Writing Mechanics, Citations, and APA Style
3 to >2 pts
Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.
2 to >1 pts
Moderately use the literature and other resources to inform their work. Moderately use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail.
1 to >0 pts
Ineffectively uses the literature and other resources to inform their work. Ineffectively use of citations and extended referencing. APA style and writing mechanics need serious attention.
0 pts
Missing criteria and/or submission.
/ 3 pts
Total Points: 0
Submission Instructions:
Nursinghomeworkdesk.com is a unique service that provides guidance with different types of content. Please rest assured that the service is absolutely legal and doesn’t violate any regulations.
Home
Writing Services
About Us
Pricing

Email:
[email protected]
Phone:
+1 (231)-518-0303
