Our Services

Get 15% Discount on your First Order

[rank_math_breadcrumb]

focus note

PRAC 6541:
Primary Care of Adolescents and Children


Focused SOAP Checklist

SUBJECTIVE:

·
Chief Complaint: Did I state briefly in the patient’s own words

·
History of present illness: Did I write a paragraph in the order of the 7 attributes & did I put the 7 attributes in a concise list in the chart (OLD CART-if you don’t know it, please look it up)

·
Medications: did I list each medication and reason.

·
Allergies: Did I include specific reactions to medications, foods, and insects, environmental?

·
Past Medical History (PMH): Did I list all the patient
Illnesses, hospitalizations? Did I Include childhood illnesses

·
Past Surgical History (PSH): Did I list the
dates, indications and types of operations?

·
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function.

·
Personal/Social History: Tobacco use, Alcohol use, Drug use, risky sexual behavior. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history, school/daycare etc

·
Immunizations: Did I include
Last Tdap, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) HPV if applicable

·
Family History: Did I list for Parents, Grandparents, siblings, children?

·
Review of Systems (SUBJECTIVE DATA): Did I include the systems related to my Chief Complaint and chronic conditions? Did I type detailed description? I did NOT use WNL. I was specific in my descriptions (see health assessment textbook).
Did I remember this is what the patient says and not what I observed? Did I include the cardiovascular and respiratory system regardless of chief complaint?

Physical Exam: (OBJECTIVE DATA) This is what YOU see/touch/hear/smell

· Did I list the vital signs as the first thing in the objective section? Did I include the BMI for adults? Did I include the percentile for the ht, wt, bp etc for pediatrics?

· Did I examine the systems that are pertinent to the CC, HPI, and History. Did I describe what I observed? Did I never use WNL or normal? Did I describe what I observed during the physical exam?

· Did I include the systems in a list format?

· Did I include cardiovascular and respiratory systems regardless of cc?

· Did I delete the systems I did not review?

ASSESSMENT:

· Did I put my priority diagnosis in bold for EACH CC?

· Did I include at least 3 differentials(DD) after the priority diagnosis for EACH of my CC?

· Did I explain what each DD is, use references to explain and tell how you ruled in or ruled out each DD? (AND does your ROS and PE reflect this?)

· Did I include a reference citation for each diagnosis under the assessment area?

· Are my assessments concise and in a chart format?

· Did I put my differential diagnosis in order by priority?

· Did I provide a detailed rationale for each diagnosis?

Holistic care:

· Did I cover existing diagnoses and whether any changes need to be made?

· Did I include needed preventative care based on my patient’s age and risk factors?

PLAN:

· Did I include a treatment plan?

· Did I address if labs, x-rays, etc. were needed?

· Did I include a pharmacological plan and citation for EBP?

· Did I include non-pharmacological strategies?

· Did I discuss alternative therapies if applicable?

· Did I state when the patient needs a follow-up?

· Did I indication if any referrals or consultations were necessary or not necessary?

· Did I write a rationale based on evidence?

·
Health Promotion: Did I address this area? Did I state what the patient/ family need to do to promote their health based on the USPTF for adults or Bright Futures for children? Did I document my citations?

·
Disease Prevention: Did I do these based on recommendations from USPTF for adult’s or Bright Futures for children based on
the patient’s age? Did I state what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc? Did I cite the source?

REFLECTION:

· Did I state what I learned from this experience?

· Did I state what I would you do differently or if I would do everything the same and the rationale?

· Did I state if I either agreed or disagreed with my preceptor
based on evidence (and cite references for EBP?

· Did I state what I would do if the person was insured versus if the person was not insured? Indicate how this would change your plan.

· Did I state the community resources in my area?

APA

· Do I have a minimum of 3 scholarly journal articles? (NONE OF WHICH ARE PATIENT EDUCATION SITES THAT I GOOGLED)

· Did I use at least 3-4 course resources?

· Do I have the paper in a neat format?

· Did I list my references in APA format?

Developed by Joyce Turner, NP. Revision 2/22/17 by Nancy Hadley, DNP, APRN, FNP-BC

© 2020 Walden University 1

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Telehealth Technology and Change During the Pandemic

Purpose: To describe the change in the use of technology during the pandemic, in particular telehealth;  Purpose: To describe the change in the use of technology during the pandemic, in particular telehealth; to write a scientific paper using 7th edition APA formatting. Tacks: Visit the online source for the Institute of Medicine’s 2012

DNP Goals

An explanation of your personal motivations and goals in pursuing the DNP degree. A description of the expectations and role of a nurse with a practice doctorate and how they may differ from those of a nurse with a research doctorate. A description of how, as a DNP-prepared nurse, you

BA WEEK 4 ASSNG

To Prepare: Select a bill that has been proposed (not one that has been enacted) using the congressional websites provided in the Learning Resources.

WEEK 3 – DISC – 6050

Review the Resources and reflect on efforts to repeal/replace the Affordable Care Act (ACA). Consider who benefits the most when policy is developed and in the context of policy implementation. By Day 3 of Week 3 Post an explanation for how you think the cost-benefit analysis in terms of legislators being

mental Health

Reflect on your professional growth you have experienced in this course. · Identify 2 key skills or concepts you have learned Eating disorder: Binge, Anorexia, Bulimia Neuro disorder: ADHD, Autism OCD Borderline disorder · How do you feel more prepared to provide compassionate, effective care to clients with mental health

WK 4 ASSIGN EPID

Back to Week at a Glance Epidemiologic Study Designs As introduced in the first few weeks of this course, investigators use various epidemiological study designs to study health problems and the effects of health interventions. You have examined several study designs, including descriptive designs (in Week 2) and analytic study

WK 4 DISC. EPID

Back to Week at a Glance Randomized Trials in Epidemiology Imagine that researchers are conducting a randomized controlled trial of a high-fiber supplement as a preventive measure in persons at increased risk of type 2 diabetes. People enrolled in the study are disease free at the time they agree to

WK 4 DIS DATA

Self-Study: Comparison of Means, Part 1 Throughout the course, there will be a self-study Discussion pertaining to an important concept or topic covered within the assigned week. These Discussions are designed to give you the opportunity to collaborate with your peers and faculty, test your knowledge, ask questions, practice research

soap Note

PMHNP Problem-Focused SOAP Note (Use this template for this Assignment) Demographic Data · Patient age and Patient’s gender identity · MUST BE HIPAA compliant. Subjective Chief Complaint (CC): · Place the patient’s CC complaint in Quotes History of Present Illness (HPI): · Reason for an appointment today. · The events

C6A2

Instructions: First, select one of the local, national, or global nonprofit organizations or government agencies presented in the Assessment 02 Supplement: Community Resources  . Then research the nonprofit organization or government agency that you selected. Determine how the organization or agency contributes to public health and safety improvements, promotes equal opportunity,

C5

Introduction: This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem. T o prepare for your assessment, you will research the literature on your selected health care

NUR 505 530 DISCUSSION

Need your expertise for this wee assignment. 505 DIVERSITY IN ADV HLTH PRACTIC Transcultural Care After studying Module 1: Lecture Materials & Resources, discuss the following: To provide culturally diverse nursing care, describe the six cultural phenomena that are evident in all cultural groups.     Submission Instructions: • Your initial post

Discussion

United States Preventive Service Taskforce (USPSTF) Following the guidelines of the United States Preventive Service Taskforce (USPSTF), discuss and describe the screening recommendations for the following: · Cervical cancer · Breast cancer · Osteoporosis · Colorectal cancer · Lung cancer · Ovarian cancer · Intimate partner violence (IPV). Submission Instructions:

Health Assessment

Assignment A Introduction: The link between the environment and health has been well established. Both natural and manmade environments can affect the health of individuals who live in the community. The nurse must be cognizant of the individual’s home environment impact so that preventive and corrective actions can be taken

Asssigment

Historical Perspective Develop an essay of a minimum of three pages explaining the advocacy efforts of Lillian Wald, public health nurses in urban and rural settings, and nurse practitioners used to effect change in health care. Submission Instructions: · Your post should be at least six hundred words, formatted, and

Nursing Homework

Attached  2 Discussion Student’s Name Institutional Affiliation Professor’s Name Course Name Due Date Improving Follow-Up After Hospitalization for Mental Illness (FUH) involves improved communication, proactive patient participation, and novel technology. Optimizing discharge planning is crucial to prompt follow-up. Poor discharge planning may cause missing follow-up visits, readmission rates, and mental

Health Assessment

*****This is an proposal of the project that I will implement ***** Title of your project. “Understanding the importance of early and adequate prenatal care. Planned date(s) of implementation. March 24, 2025 The facility where you plan to conduct your PEEP live health teaching session. ***I planned to conduct my

Help with concept map

Need help with concept map NR586NP Concept Map Summary Template General Instructions · Carefully review the Week 2 Concept Map and Summary Assignment guidelines and rubric. · After completing your concept map, complete each section of the template below using complete sentences. Use of the template is required. If the