Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore t

Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore t
Episodic/Focused SOAP Note Template ? Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient?s own words – for instance “headache”, NOT “bad headache for 3 days?. HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was ?headache?, the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance). PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes neededSoc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system. Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: ?enies weight loss, fever, chills, weakness or fatigue. HEENT: ?yes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: ?enies hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: ?enies rash or itching. CARDIOVASCULAR: ?enies chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: ?enies shortness of breath, cough or sputum. GASTROINTESTINAL: ?enies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: ?urning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY. NEUROLOGICAL: ?enies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: ?enies muscle, back pain, joint pain or stiffness. HEMATOLOGIC: ?enies anemia, bleeding or bruising. LYMPHATICS: ?enies enlarged nodes. No history of splenectomy. PSYCHIATRIC: ?enies history of depression or anxiety. ENDOCRINOLOGIC: ?enies reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: ?enies history of asthma, hives, eczema or rhinitis. O. Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use ?WNL? or ?normal.? You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc. Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines) A. Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines. P.? This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. References You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. ?2021 Walden University, LLC Page 3 of 3
Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore t
This criterion is linked to a Learning OutcomeUsing the Episodic/Focused SOAP Template: ?Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned. ??rovide evidence from the literature to support diagnostic tests that would be appropriate for your case. 50?o >44.0?ts Excellent The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 44?o >38.0?ts Good The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 38?o >32.0?ts Fair The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected. 32?o >0?ts Poor The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 50?ts This criterion is linked to a Learning Outcome?? List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 35?o >29.0?ts Excellent The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected. 29?o >23.0?ts Good The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected. 23?o >17.0?ts Fair The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 17?o >0?ts Poor The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. 35?ts This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5?o >4.0?ts Excellent Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4?o >3.0?ts Good Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3?o >2.0?ts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%?79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 2?o >0?ts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. 5?ts This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation 5?o >4.0?ts Excellent Uses correct grammar, spelling, and punctuation with no errors. 4?o >3.0?ts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3?o >2.0?ts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors. 2?o >0?ts Poor Contains many (= 5) grammar, spelling, and punctuation errors that interfere with the reader?s understanding. 5?ts This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing,?argins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5?o >4.0?ts Excellent Uses correct APA format with no errors. 4?o >3.0?ts Good Contains a few (1 or 2) APA format errors. 3?o >2.0?ts Fair Contains several (3 or 4) APA format errors. 2?o >0?ts Poor Contains many (= 5) APA format errors. 5?ts Total Points:?00 PreviousNext

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