History

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mpryor4452

Santé & Médecine Business

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Section 3: Health Habits and Lifestyle ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Section 4: Personal Health History ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Section 5: Hospitalizations, Injuries, Accidents, and Surgeries ,[object Object],[object Object]

Section 6: Family History ,[object Object],[object Object],[object Object]

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For this assignment, you are to complete a clinical case - narrated PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below. You are to approach this clinical scenario as if it is a real patient in the clinical setting. Instructions: Step 1 - Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps. Step 2 - Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note. Step 3 - Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations. Example of Steps 1 - 3: You decided on Angina after reading the clinical case scenario (Step 1) Review of Symptoms (list of classic symptoms): CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone GI: indigestion, heartburn, nausea, cramping Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth Resp: shortness of breath Musculo: weakness Step 4 – Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations. Example of Step 4: You determined the patient has Angina in Step 1 Physical Examination (list of classic exam findings): CV: RRR, murmur grade 1/4 Resp: diminished breath sounds left lower lobe Step 5 - Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA. Step 6 - Develop a treatment plan for the diagnoses. Only use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan must address the following: a) Medications (include the dosage in mg/kg, frequency, route, and the number of days) b) Laboratory tests ordered (include why ordered and what the results of the test may indicate) c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate) d) Vaccines administered this visit & vaccine administration forms given, e) Non-pharmacological treatments f) Patient/Family education including preventive care g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section) h) Follow-up appointment wit.

For this assignment, you are to complete aclinical case - narr.docx

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For this week's discussion, we will be looking at local or national response protocols that were initiated during a critical incident, and you will choose your topic! Search reputable local and national media for a man-made disaster to discuss. Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks. In your initial post, describe the incident and address the following: · Determine the incident type and explain your reasoning. · What resources were deployed for this incident? · What protocols were implemented successfully, and which were unsuccessful? · Discuss way to improve the response to this type of incident in the future. Support your answer with evidence. Please provide a working link to your story source. NUR 634 SOAP Note Guide and Template Patient SOAP Note Charting Procedures S = Subjective O = Objective A = Assessment P = Plan Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it. Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing. Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI. Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded. SOAP NOTE TEMPLATE **Please delete the instructions in each section prior to submitting the assignment Student Name: Date: Course: Subjective: Patient Demographics: (age, gender, gender identity, ethnicity, etc.) Chief Complaint: “quote patient” History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS) PMH: dates in reverse chronological order. PSH: surgery dates in reverse chronological order. Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies Untoward Medication Reactions: include type ...

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Diagnostic and Clinical Reasoning Paper Assignment The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases. 1. Select a patient encounter from your current clinical experience. 2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter. You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper. 3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual. Below is the overview of the required elements for this assignment: *Title Page (Page 1) : Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date. *Subjective (Start of Page 2) : Follow APA guidelines for running head on page 2 and subsequent pages. CC: chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased. HPI: history of present illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary] PMH: past medical history - This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, and routes of administration. Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. Click on the link below to explore the CDC’s information on the ‘social determinants of health’. https://www.cdc.gov/socialdeterminants/ Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Health Maintenance/Promotion: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Click on the link below to access information about current guidelines. https://www.uspreventiveservicestaskforce.org/ Review of Systems (R ...

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see attachments I have complete a portion of the assignment but need the rest of the Diagnostic and Clinical Reasoning Paper Assignment The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases. 1. Select a patient encounter from your current clinical experience. 2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter. You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper. 3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual. Below is the overview of the required elements for this assignment: *Title Page (Page 1) : Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date. *Subjective (Start of Page 2) : Follow APA guidelines for running head on page 2 and subsequent pages. CC: chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased. HPI: history of present illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary] PMH: past medical history - This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, and routes of administration. Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. Click on the link below to explore the CDC’s information on the ‘social determinants of health’. https://www.cdc.gov/socialdeterminants/ Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Health Maintenance/Promotion: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Click on the link below to access information about c ...

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Guidelines for Achieving a Compliant Query Practice (2016 Update) Editor’s Note: This Practice Brief supersedes the February 2013 Practice Brief titled "Guidelines for Achieving a Compliant Query Practice" The only change in this version of the practice brief was to update the Coding Clinic reference from ICD-9-CM to ICD-10-CM and ICD-10-PCS. In court an attorney can’t “lead” a witness into a statement. In hospitals, coders and clinical documentation specialists can’t lead healthcare providers with queries. Therefore, appropriate etiquette must be followed when querying providers for additional health record information. A query is a communication tool used to clarify documentation in the health record for accurate code assignment. The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment. The final coded diagnoses and procedures derived from the health record documentation should accurately reflect the patient’s episode of care. The guidance of this practice brief augments and, where applicable, supersedes prior AHIMA guidance on queries. The intent of this practice brief is not to limit clinical communication for purposes of patient care. Rather it is to maintain the integrity of the coded healthcare data. All professionals are encouraged to adhere to these compliant querying guidelines regardless of credential, role, title, or use of any technological tools involved in the query process. A proper query process ensures that appropriate documentation appears in the health record. Personnel performing the query function should focus on a compliant query process and content reflective of appropriate clinical indicators to support the query. When and How to Query The generation of a query should be considered when the health record documentation: · Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent · Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis · Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure · Provides a diagnosis without underlying clinical validation · Is unclear for present on admission indicator assignment Although open-ended queries are preferred, multiple choice and “yes/no” queries are also acceptable under certain circumstances. Query Example: Clarification for Specificity of a Diagnosis Documentation: Obtunded patient admitted with three-day history of nausea and vomiting. CXR revealed right lower lobe (RLL) pneumonia. Clindamycin ordered. Leading query: Is the patient’s pneumonia due to aspiration? Nonleading query: Can the etiology of the patient’s pneumonia be further specified? It is noted in the admitting history and physical examination (H&P) this obtunded patient had a history of nausea and vomiting prior to admission ...

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Initial Psychiatric SOAP Note Template There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting. Criteria Clinical Notes Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) Subjective Verify Patient Name: DOB: Minor: Accompanied by: Demographic: Gender Identifier Note: CC: HPI: Pertinent history in record and from patient: X During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME. Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory. Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature. SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early childhood, school hx, behavior, etc… Nutritional status (this is an important component to gauge how well the mind and body are being nourished for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which affects function of cognition, mood, etc…) Past Psychiatric Hx: Previous psychiatric diagnoses: none reported. Describes stable course of illness. Previous medication trials: none reported. Safety concerns: History of Violence to Self: none reported History of Violence t .

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Comprehensive SOAP Template This template is for a full history and physical. For this course include only areas that are related to the case. Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note. O = onset of symptom (acute/gradual) L= location D= duration (recent/chronic) C= character A= associated symptoms/aggravating factors R= relieving factors T= treatments previously tried – response? Why discontinued? S= severity SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): In just a few words, explain why the patient came to the clinic. History of Present Illness (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. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list: 1. Location 2. Quality 3. Quantity or severity 4. Timing, including onset, duration, and frequency 5. Setting in which it occurs 6. Factors that have aggravated or relieved the symptom 7. Associated manifestations Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency. Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance. Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations. Past Surgical History (PSH): Include dates, indications, and types of operations. Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors. Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits. Immunization History: Includelast Tdap, Flu, pneumonia, etc. Significant Family History: Include history of parents, grandparents, siblings, and children. Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference. Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text). General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here. HEENT: Neck: Breasts: Respiratory: Cardiovascular/Peripheral Vascular: Gastrointestinal: Genitourinary: Mu.

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Benchmark - Academic Clinical History and Physical Note Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating evidence-based plans of care. Complete an academic clinical history and physical note based on a patient seen during clinical. In your assessment, provide the following. ( Acute Care Hospital) History and Physical Note 1. Chief complaint/reason for admission/visit/consult. 2. HPI for the H&P or consult notes. 3. Medical, surgical, family, social, and allergy history. 4. Home medications, including dosages, route, frequency, and current medications, if a consultation note 5. Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system). 6. Vital signs and weight. 7. Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam. 8. Lab/Imaging/Diagnostic test results (including date). (CPT codes) Assessment and Clinical Impressions 1. Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale. (ICD-10 codes) 2. Include a complete list of all diagnoses that are both acute and chronic. 3. List the differential diagnoses and chronic conditions in order of priority. Plan Component Management and Plan Criteria Incorporation 1. Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale. 2. Discuss disposition and expected outcomes. 3. Identify and address health education, health promotion, and disease prevention. 4. Provide case summary with ethical, legal, and geriatric considerations. Consider potential issues, even if they are not evident. General Requirements Incorporate at least three peer-reviewed articles in the assessment or plan. While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance. Benchmark Information This benchmark assignment assesses the following programmatic competency: MSN Acute Care Nurse Practitioner 6.1: Determine differential diagnoses using physiological and pathophysiological evidence. .

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Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis. Incorporate the following into your responses in the template: Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? Objective: What observations did you make during the psychiatric assessment?  Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). .

Complete and submit your Comprehensive Psychiatric Evaluation, i.docx

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Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis. Incorporate the following into your responses in the template: Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? Objective: What observations did you make during the psychiatric assessment?  Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). NRNP_PRAC_6635_ComprehensivePsychiatricEvaluationExemplar_rev.4.2022.docx NRNPPRAC6635ComprehensivePsychiatricEvaluationTemplate.docx .

Complete and submit your Comprehensive Psychiatric Evaluation, inclu.docx

richardnorman90310

Initial Psychiatric Interview/SOAP Note Template Criteria Clinical Notes Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) Subjective Verify Patient Name: Susan DOB: not provided Minor: NA Accompanied by: self Demographic: NA Gender Identifier Note: Female CC: “I have been feeling anxious, depresssed, high blood pressure, irregular heartbeat, elevated body temperature, crying spells for the last 2 days” . HPI: Susan is a midde aged woman who reports to the healthcare clinic reporting several symptoms that she has observed over the period of the last two days. She reports having high blood pressure, an irregular heartbeat, depression, anxiety, and an increase in body temperature. Susan doesn't realize that she shows signs of alcohol dependence and physiological dependence, which downplays the seriousness of her alcohol usage. This diagnosis is supported by the withdrawal symptoms that appear to be becoming more tolerable as well as by the sustained and increased alcohol consumption despite the harm it does to social interactions and job performance. She has also increased her alcohol consumption to ease withdrawal symptoms. s He has a history of drinking, which has caused him to skip work and even get arrested. She downplays her alcohol consumption and justifies how often and how much she drinks. Pertinent history in record and from patient: Alcohol withdrawal During assessment: Patient is cam and corparative Patient seemed to be suffering from serious cases of both anxiety and despair judging from her crying spells. Patient denies hallucinating. The patient has nomal thought process. . SI/ HI/ AV: patient denies signs of suicidal ideation and violent behavior. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported Past Psychiatric Hx: Previous psychiatric diagnoses: NKDA Describes stable course of illness. Previous medication trials: not reported Safety concerns: History of Violence to Self:none reported History of Violence t o Others: none reported Auditory Hallucinations: not reported Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Priorsubstance abuse treatment: not reported Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure .

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