NSG 6440 Practicum IV Family Health – Primary Care Week 4 SOAP Note

NSG 6440 Practicum IV Family Health – Primary Care Week 4 SOAP Note

NSG 6440 Practicum IV Family Health – Primary Care Week 4 SOAP Note

NSG 6440 Practicum IV Family Health – Primary Care

Week 4 SOAP Note

SOAP Note

Using this template, complete one SOAP note from a patient in your current NSG6440 clinical experience. The completed note should be submitted to the Submissions Area.

Submission Details:

Name your SOAP note document SU_NSG6440_W4_SOAPLastName_FirstInitial.doc.

Submit your document to the Submissions Area by the due date assigned.

This is a Pass/Fail assignment. A minimum of 15 points are needed, based on the assignment rubric, to pass.

Name:		Pt. Encounter Number:
Date:		Age:		Sex:
	SUBJECTIVE
CC: Reason given by the patient for seeking medical care “in quotes”
HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
PMH Allergies:   Medication Intolerances:   Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
ROS
General Weight change, fatigue, fever, chills, night sweats, and energy level			Cardiovascular Chest pain, palpitations, PND, orthopnea, and edema
Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles			Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB
Eyes Corrective lenses, blurring, and visual changes of any kind			Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools
Ears Ear pain, hearing loss, ringing in ears, and discharge			Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDs Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints

Week 1 Knowledge Check

1. What has been one of the focus areas of law in the United States over the past few decades?

·         A. Removing antidiscrimination laws

·         B. Moving away from the domain of education

·         C. Guaranteeing consistency and equality

·         D. Promoting the domination of tribal societies

2. Identify the true statement about the role of law in the United States.

·         A. The law has no influence on commerce and business transactions.

·         B. The law is yet to introduce legal mechanisms to ensure equality in the workplace.

·         C. The law plays a role in fostering trust and reliability among merchants and consumers.

·         D. The focus of law has now significantly shifted to domination and power.

3. Which of the following is one of the purposes of law today?

·         A. Acting as a change agent for commerce

·         B. Promoting domination

·         C. Embracing discrimination laws

·         D. Excluding commercial transactions from the purview of law

4. Identify the true statement about the American judiciary.

·         A. All courts interpret laws and take decisions independently.

·         B. Certain courts have the duty to evaluate the actions of other courts.

·         C. All courts are charged with the responsibility of judicial review.

·         D. Every court has the authority to hear all kinds of cases.

5. What is the function of an appellate court?

·         A. To review petitions filed by losing parties

·         B. To review the actions of federal courts

·         C. To conduct trial proceedings for lawsuits

·         D. To conduct trials for issues involving violations of federal statutes

6. Identify the courts that conduct primary trials for issues that involve federal matters such as federal regulations and statutes. The courts also hear a range of matters and provide decisions that are binding only on the parties involved.

·         A. Appellate courts

·         B. Circuit Courts of Appeal

·         C. U.S. District Courts

·         D. State trial courts

7.  What is true about arbitration as an alternative form of dispute resolution?

·         A. The arbitrator functions like a judge in a standard trial.

·         B. The arbitrator is not authorized to demand the testimony of witnesses in any dispute.

·         C. The arbitrator’s final decision must be approved by a higher court.

·         D. The arbitrator’s decision cannot be questioned under any circumstances.

8. Sigma Inc. and Beta LLC. are two companies involved in a dispute. Both companies have agreed to appoint a third party, an attorney, to listen to their arguments and help them reach an agreement. The third party, however, will not render any kind of decision for the two parties involved. What type of alternative form of dispute resolution is being used by Sigma Inc. and Beta LLC.?

·         A. Arbitration

·         B. Mediation

·         C. Expert evaluation

·         D. Trial

9. In certain cases, the legal issues involve the intricacies of a specific industry or profession. In such cases, which type of alternative dispute resolution is used in which a neutral professional is hired to assess and evaluate facts and arguments. The professional is expected to come up with an appropriate solution or recommendation. The professional could also collect more information, if required, for the case.

·         A. Mediation

·         B. Negotiation

·         C. Standing

·         D. Expert evaluation

Also Check Out: NSG 6440 Practicum IV Family Health – Primary Care Week 3 SOAP Note

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ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.

Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.

One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.

I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.

In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.

Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).

Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).

Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.

I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.

As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.

It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.