Episodic Visit: Gynecology Focused Note
Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses
can piece together facts to construct a relevant history that can lead to assessment and treatment.
For this Focused Note Assignment, you will select a patient with gynecologic conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
Resources
· Fowler, G. C. (2019).
Pfenninger and Fowler’s Procedures for Primary Care (4th ed.). Elsevier.
· Chapter 136, “Insertion and Removal of Nexplanon” (pp. 946–951)
· Chapter 137, “Pessaries” (pp. 952–959)
· Chapter 138, “Treatment of Noncervical Condylomata Acuminata” (pp. 960–969)
· Chapter 139, “Vulvar Biopsy” (pp. 970–973)
Practicum Resources
·
Walden University Field Experience.Links to an external site.
(n.d.-a).
Field experience: College of Nursing.Links to an external site.
· Walden University Field Experience. (n.d.-c).
Student practicum resources: NP student orientation
.Links to an external site.
· Walden University Field Experience. (n.d.-b).
MSN nurse practitioner practicum manual
. Retrieved fromLinks to an external site.
· HSoft Corporation. (n.d.).
Meditrek
Links to an external site.
.
Note: Use this website to log in to Meditrek to report your clinical hours and patient encounters.
·
Document:
Focused SOAP Note Template (Word document)
Download Focused SOAP Note Template (Word document)
Clinical Guideline Resources
· As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for the CDC -zika in pregnancy, etc.).
·
American College of Obstetricians and Gynecologists.Links to an external site.
(n.d.).
·
American Cancer Society.Links to an external site.
(n.d.).
·
ANA Enterprise.Links to an external site.
(n.d.).
·
Centers for Disease Control and Prevention.Links to an external site.
(n.d.).
· HealthyPeople 2030. (2020).
Healthy People 2030 framework.Links to an external site.
·
The American Association of Nurse Practitioners.Links to an external site.
(2020).
· U.S. Preventive Services Task Force. (n.d.-b).
Search and filter all recommendation topics
.Links to an external site.
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To prepare:
· Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.
· Select a patient that you examined during the last three weeks. With this patient in mind, address the following in your Focused Note Template.
Assignment
·
Subjective: What details did the patient provide regarding her personal and medical history?
·
Objective: What observations did you make during the physical assessment?
·
Assessment: What were your differential diagnoses? Provide a minimum of
four possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
·
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
·
Reflection notes: What would you do differently in a similar patient evaluation?
