Episodic Visit: Adolescent Focused Note (Ages 13-17)
SENARIO- SICK VISIT-PATIENT SORE THROAT.
Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will work with an adolescent patient that you examined during the last 3 weeks and complete a Focused Note Template in which you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. In this week’s Learning Resources, please refer to the Focused Note resources for guidance on writing Focused Notes.
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
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To prepare:
· Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
· Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
· Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
Assignment
· Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. 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? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Note: Your Focused Note Assignment must be signed by Day 7 of Week 3.
SICK VISIT-PATIENT SORE THROAT.
Rubric
PRAC_6541_Week3_Assignment2_Rubric
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PRAC_6541_Week3_Assignment2_Rubric |
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Criteria |
Ratings |
Pts |
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This criterion is linked to a Learning OutcomeOrganization of Write-up |
10 to >6.0 ptsExcellentAll information organized in logical sequence; follows acceptable format and utilizes expected headings. 6 to >3.0 ptsGoodInformation generally organized in logical sequence; follows acceptable format and utilizes expected headings. 3 to >0.0 ptsFairErrors in format; information intermittently organized. Headings are used some of the time. 0 ptsPoorErrors in format; information disorganized. Headings are not used appropriately. |
10 pts |
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This criterion is linked to a Learning OutcomeThoroughness of History |
20 to >15.0 ptsExcellentThoroughly documents all pertinent history components for type of note; includes critical as well as supportive information. 15 to >11.0 ptsGoodDocuments most pertinent examination components. 11 to >7.0 ptsFairDocuments some pertinent examination components. 7 to >0 ptsPoorPhysical examination cursory; misses several pertinent components. |
20 pts |
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This criterion is linked to a Learning OutcomeHistory of Present Illness |
10 to >6.0 ptsExcellentThoroughly documents all 8 aspects of HPI and pertinent other data relevant to chief complaint. Includes critical as well as supportive information. 6 to >4.0 ptsGoodDocuments at least 6 aspects of the HPI and pertinent other data relevant to chief complaint. Includes critical information. 4 to >2.0 ptsFairDocuments at least 4 aspects of HPI and some data pertinent to chief complaint. Lacks some critical information or rambling in history. 2 to >0 ptsPoorMissing many aspects of HPI and pertinent data. Critical information missing. |
10 pts |
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This criterion is linked to a Learning OutcomeThoroughness of Physical Exam |
10 to >7.0 ptsExcellentThoroughly documents all pertinent examination components for type of note. 7 to >4.0 ptsGoodDocuments most pertinent examination components. 4 to >2.0 ptsFairDocuments some pertinent examination components. 2 to >0 ptsPoorPhysical examination cursory; misses several pertinent components. |
10 pts |
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This criterion is linked to a Learning OutcomeDiagnostic Reasoning |
10 to >7.0 ptsExcellentAssessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests. 7 to >4.0 ptsGoodAssessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems. 4 to >2.0 ptsFairAssessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests. 2 to >0 ptsPoorAssessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests. |
10 pts |
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This criterion is linked to a Learning OutcomeTreatment Plan/Patient Education |
20 to >15.0 ptsExcellentTreatment plan addresses all issues raised by diagnoses, excellent insight into patient’s needs. Medications prescribed are appropriate and full prescription is included. Evidence based decisions. Cost effective treatment. 15 to >10.0 ptsGoodTreatment plan addresses most issues raised by diagnoses. Medications prescribed are appropriate but include 1 or 2 error in writing prescription. 10 to >5.0 ptsFairTreatment plan fails to address most issues raised by diagnoses. Medications are inappropriate or include 3 or more errors in writing prescription. 5 to >0 ptsPoorMinimal treatment plan addressed. Medications are inappropriate or poorly written prescription. |
20 pts |
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This criterion is linked to a Learning OutcomePatient Education / Follow Up / Reflection |
10 to >8.0 ptsExcellentPatient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Follow up plan in appropriate and reflects acuity of illness. Reflection is thoughtful and in depth. 8 to >5.0 ptsGoodPatient education addresses most issues raised by diagnoses. Follow up plan is appropriate but lacks specifics Reflection is thoughtful and in depth. 5 to >3.0 ptsFairPatient education fails to address most issues raised by diagnoses. Follow up plan is lacking specifics or is inappropriate for patient acuity. Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently. 3 to >0 ptsPoorMinimal patient education addressed. Follow up plan is inappropriate Reflection is absent. |
10 pts |
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This criterion is linked to a Learning OutcomeWritten Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation. Professional language utilized |
5 ptsExcellentUses correct grammar, spelling, and punctuation with no errors. Professional language utilized. 4 ptsGoodContains a few (1-2) grammar, spelling, and punctuation errors. Contains a few errors (1 or 2) in professional language use. 2 ptsFairContains several (3-4) grammar, spelling, and punctuation errors. Contains several errors (3 -4) in professional language use. 0 ptsPoorContains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Contains many errors in professional language use. |
5 pts |
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This criterion is linked to a Learning OutcomeScholarly References and Clinical Practice Guidelines. The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Clinical practice guidelines are included if applicable. |
5 ptsExcellentContains parenthetical/in-text citations and at least 3 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable. 4 ptsGoodContains parenthetical/in-text citations and at least 2 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable. 2 ptsFairContains parenthetical/in-text citations and at least 1 evidenced based reference less than 5 years old is listed. Clinical practice guidelines are not cited if applicable. 0 ptsPoorContains no parenthetical/in-text citations and 0 evidenced based references listed. Clinical practice guidelines are not cited if applicable. |
5 pts |
Total Points: 100
