Focused Note

Home>Homework Answsers>Nursing homework helpnursingMSNa year ago25.09.202420Report issuefiles (3)WK9FocusedNote.docxPRAC_6531_Episodic_Focused_Note_Template_Final1.docxWeek9_Assignment2FocusedNote.pdfWK9FocusedNote.docxIn clinical settings, patients often present with musculoskeletal conditions such as chronic back pain. Drugs are typically prescribed to help manage this type of pain for patients. There are many different pain medicines, and each one has benefits and risks. To add to the complexity, each patient may also have a slightly different response to a pain reliever. When over-the-counter medications do not address a patient’s pain, more powerful prescription pain relievers, such as opioids, can be effective but also sometimes have serious side effects. There is also a risk of addiction. More than 70,000 people died in 2017 from drug overdoses, and almost 68% involved a prescription or illicit opioid. Drug overdose deaths continue to increase in the United States (Centers for Disease Control and Prevention, n.d.).For the advanced practice nurse, these statistics highlight the need to effectively screen for, diagnose, and manage opioid use. It is essential to carefully observe and watch for signs of drug abuse during patient evaluations. Because not all musculoskeletal conditions require narcotics, a thorough patient evaluation will help to ensure the development of an appropriate treatment plan with patient safety in mind.This week, you will continue to engage with Meditrek, recording your clinical hours and patient encounters. You will also learn about evaluation and management of musculoskeletal conditions in the reading selections as well as conduct a patient evaluation of a patient from your practicum experience who has a musculoskeletal condition. Based on diagnostic and treatment options you identify for the patient, you will identify a primary diagnosis, as well as a treatment and management plan.ReferenceCenters for Disease Control and Prevention (n.d.).CDC’s response to the opioid overdose epidemic.https://www.cdc.gov/opioids/LEARNING OBJECTIVESStudents will:· Describe clinical hours and patient encounters· Formulate diagnoses for adult patients· Justify adult patient treatment options· Advocate health promotion and patient education strategies across the adult lifespan· Synthesize the assessment and diagnosis of health conditions for a clinical patient· Fowler, G. C. (2020).Pfenninger and Fowler’s procedures for primary care(4th ed.). Elsevier.· Chapter 174, “Shoulder Dislocations” (pp. 1163–1167)· Chapter 175, “Ankle and Foot Splinting, Casting, and Taping” (pp. 1168–1175)· Chapter 176, “Cast Immobilization and Upper Extremity Splinting” (pp. 1176–1185)· Chapter 177, “Knee Braces” (pp. 1186–1192)· Chapter 178, “Fracture Care” (pp. 1193–1211)· Chapter 180, “Joint and Soft Tissue Aspiration and Injection (Arthrocentesis)” (pp. 1221–1239)· Chapter 181, “Trigger-Point Injection” (pp. 1240–1244)· Chapter 235, “Principles of X-Ray Interpretation” (pp. 1566–1575)PRAC_6531_Episodic_Focused_Note_Template_Final1.docxMaster of Science in Nursing   PRAC 6531:Primary Care of Adults Across the Lifespan PracticumEpisodic/Focus Note TemplatePatient Information:Initials, Age, Sex, RaceS.CC(chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT “bad headache for 3 days”).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. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:Location: headOnset: 3 days agoCharacter: pounding, pressure around the eyes and templesAssociated signs and symptoms: nausea, vomiting, photophobia, phonophobiaTiming: after being on the computer all day at workExacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely betterSeverity: 7/10 pain scaleCurrent Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Allergies:include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance).PMHx: include immunization status (note date oflast tetanusfor all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes neededSoc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:General:Head:EENT: etc. You should list these in bullet format and document the systems in order from head to toe.Example of Complete ROS:GENERAL: No weight loss, fever, chills, weakness, or fatigue.HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.SKIN: No rash or itching.CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.RESPIRATORY: No shortness of breath, cough, or sputum.GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.HEMATOLOGIC: No anemia, bleeding, or bruising.LYMPHATICS: No enlarged nodes. No history of splenectomy.PSYCHIATRIC: No history of depression or anxiety.ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.ALLERGIES: No history of asthma, hives, eczema, or rhinitis.O.Physical exam: From head-to-toe, includewhat you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History.Do not use “WNL” or “normal.” You must describe what you see.Always document in head to toe format (i.e., General: Head: EENT: etc.).Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).A.Differential Diagnoses(list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.P.Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.Also included in this section is the reflection.The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).ReferencesYou are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.© 2020 Walden University 1Week9_Assignment2FocusedNote.pdfFor this Assignment, you will work with a patient with a
musculoskeletal condition that you examined during the
last three weeks. You will complete your third
Episodic/Focused Note Template Form for this course
where you will gather patient information, relevant
diagnostic and treatment information as well as reflect on
health promotion and disease prevention in light of
patient factors such as age, ethnic group, previous
medical history (PMH), socio-economic, cultural
background, etc. In this week’s Learning Resources,
please review 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.To prepare:Use the Episodic/Focused 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 based on musculoskeletal conditions. With
this patient in mind, address the following in a Focused Note: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 three 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?EPISODIC VISIT: MUSCULOSKELETAL
FOCUSED NOTERESOURCESBe sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.WEEKLY RESOURCES9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 1/5https://waldenu.instructure.com/courses/131456/files/9870301/downloadhttps://waldenu.instructure.com/courses/131456/modules/items/4993252PRAC_6531_Week9_Assignment2_RubricNote: Your Focused Note Assignment must be signed by Day 7 of Week 9.Submit your Episodic/Focused Note Assignment.(Note: You will submit two files, your Focused Note Assignment, and a Word document of
pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 9.)Before submitting your final assignment, you can check your draft for authenticity. To check your
draft, access the Turnitin Drafts from the Start Here area.1. To submit your completed assignment, save your Assignment
as WK9Assgn2_LastName_Firstinitial2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.BY DAY 7SUBMISSION INFORMATION9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 2/5Criteria Ratings Pts10 pts20 pts10 pts10 pts10 ptsOrganization of
Write-up10 to >6.0 pts
Excellent
All information
organized in logical
sequence; follows
acceptable format
and utilizes expected
headings.6 to >3.0 pts
Good
Information generally
organized in logical
sequence; follows
acceptable format
and utilizes expected
headings.3 to >0.0 pts
Fair
Errors in format;
information
intermittently
organized.
Headings are used
some of the time.0 pts
Poor
Errors in format;
information
disorganized.
Headings are not
used appropriately.Thoroughness of
History20 to >15.0 pts
Excellent
Thoroughly documents all
pertinent history
components for type of
note; includes critical as
well as supportive
information.15 to >11.0 pts
Good
Documents most
pertinent
examination
components.11 to >7.0 pts
Fair
Documents some
pertinent
examination
components.7 to >0 pts
Poor
Physical
examination
cursory; misses
several pertinent
components.History of Present
Illness10 to >6.0 pts
Excellent
Thoroughly 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 pts
Good
Documents at least
6 aspects of the HPI
and pertinent other
data relevant to chief
complaint. Includes
critical information.4 to >2.0 pts
Fair
Documents at least 4
aspects of HPI and
some data pertinent
to chief complaint.
Lacks some critical
information or
rambling in history.2 to >0 pts
Poor
Missing many
aspects of HPI
and pertinent
data. Critical
information
missing.Thoroughness of
Physical Exam10 to >7.0 pts
Excellent
Thoroughly documents
all pertinent
examination
components for type of
note.7 to >4.0 pts
Good
Documents most
pertinent
examination
components.4 to >2.0 pts
Fair
Documents some
pertinent
examination
components.2 to >0 pts
Poor
Physical examination
cursory; misses
several pertinent
components.Diagnostic
Reasoning10 to >7.0 pts
Excellent
Assessment
consistent with prior
documentation.
Clear justification for
diagnosis. Notes all
secondary problems.
Cost effective when7 to >4.0 pts
Good
Assessment
consistent with
prior
documentation.
Clear justification
for diagnosis.
Notes most4 to >2.0 pts
Fair
Assessment mostly
consistent with prior
documentation. Fails
to clearly justify
diagnosis or note
secondary problems
or orders2 to >0 pts
Poor
Assessment not
consistent with prior
documentation. Fails
to clearly justify
diagnosis or note
secondary problems
or orders9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 3/5Criteria Ratings Pts20 pts10 pts5 ptsordering diagnostic
tests.secondary
problems.inappropriate
diagnostic tests.inappropriate
diagnostic tests.Treatment
Plan/Patient
Education20 to >15.0 pts
Excellent
Treatment 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 pts
Good
Treatment plan
addresses most
issues raised by
diagnoses.
Medications
prescribed are
appropriate but
include 1 or 2 error in
writing prescription.10 to >5.0 pts
Fair
Treatment plan fails
to address most
issues raised by
diagnoses.
Medications are
inappropriate or
include 3 or more
errors in writing
prescription.5 to >0 pts
Poor
Minimal
treatment plan
addressed.
Medications are
inappropriate or
poorly written
prescription.Patient Education /
Follow Up /
Reflection10 to >8.0 pts
Excellent
Patient 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 pts
Good
Patient 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 pts
Fair
Patient 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 pts
Poor
Minimal patient
education
addressed.
Follow up plan
is inappropriate
Reflection is
absent.Written Expression
and Formatting
English writing
standards: Correct
grammar,
mechanics, and
proper
punctuation.
Professional
language utilized5 pts
Excellent
Uses correct
grammar,
spelling, and
punctuation with
no errors.
Professional
language utilized.4 pts
Good
Contains a few (1-
2) grammar,
spelling, and
punctuation errors.
Contains a few
errors (1 or 2) in
professional
language use.2 pts
Fair
Contains several
(3-4) grammar,
spelling, and
punctuation errors.
Contains several
errors (3 -4) in
professional
language use.0 pts
Poor
Contains many (≥ 5)
grammar, spelling, and
punctuation errors that
interfere with the
reader’s understanding.
Contains many errors in
professional language
use.9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 4/5Total Points: 100Criteria Ratings Pts5 ptsScholarly
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 pts
Excellent
Contains
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 pts
Good
Contains
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 pts
Fair
Contains
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 pts
Poor
Contains no
parenthetical/in-text
citations and 0
evidenced based
references listed.
Clinical practice
guidelines are not
cited if applicable.9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 5/5Week9_Assignment2FocusedNote.pdfFor this Assignment, you will work with a patient with a
musculoskeletal condition that you examined during the
last three weeks. You will complete your third
Episodic/Focused Note Template Form for this course
where you will gather patient information, relevant
diagnostic and treatment information as well as reflect on
health promotion and disease prevention in light of
patient factors such as age, ethnic group, previous
medical history (PMH), socio-economic, cultural
background, etc. In this week’s Learning Resources,
please review 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.To prepare:Use the Episodic/Focused 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 based on musculoskeletal conditions. With
this patient in mind, address the following in a Focused Note: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 three 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?EPISODIC VISIT: MUSCULOSKELETAL
FOCUSED NOTERESOURCESBe sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.WEEKLY RESOURCES9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 1/5https://waldenu.instructure.com/courses/131456/files/9870301/downloadhttps://waldenu.instructure.com/courses/131456/modules/items/4993252PRAC_6531_Week9_Assignment2_RubricNote: Your Focused Note Assignment must be signed by Day 7 of Week 9.Submit your Episodic/Focused Note Assignment.(Note: You will submit two files, your Focused Note Assignment, and a Word document of
pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 9.)Before submitting your final assignment, you can check your draft for authenticity. To check your
draft, access the Turnitin Drafts from the Start Here area.1. To submit your completed assignment, save your Assignment
as WK9Assgn2_LastName_Firstinitial2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.BY DAY 7SUBMISSION INFORMATION9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 2/5Criteria Ratings Pts10 pts20 pts10 pts10 pts10 ptsOrganization of
Write-up10 to >6.0 pts
Excellent
All information
organized in logical
sequence; follows
acceptable format
and utilizes expected
headings.6 to >3.0 pts
Good
Information generally
organized in logical
sequence; follows
acceptable format
and utilizes expected
headings.3 to >0.0 pts
Fair
Errors in format;
information
intermittently
organized.
Headings are used
some of the time.0 pts
Poor
Errors in format;
information
disorganized.
Headings are not
used appropriately.Thoroughness of
History20 to >15.0 pts
Excellent
Thoroughly documents all
pertinent history
components for type of
note; includes critical as
well as supportive
information.15 to >11.0 pts
Good
Documents most
pertinent
examination
components.11 to >7.0 pts
Fair
Documents some
pertinent
examination
components.7 to >0 pts
Poor
Physical
examination
cursory; misses
several pertinent
components.History of Present
Illness10 to >6.0 pts
Excellent
Thoroughly 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 pts
Good
Documents at least
6 aspects of the HPI
and pertinent other
data relevant to chief
complaint. Includes
critical information.4 to >2.0 pts
Fair
Documents at least 4
aspects of HPI and
some data pertinent
to chief complaint.
Lacks some critical
information or
rambling in history.2 to >0 pts
Poor
Missing many
aspects of HPI
and pertinent
data. Critical
information
missing.Thoroughness of
Physical Exam10 to >7.0 pts
Excellent
Thoroughly documents
all pertinent
examination
components for type of
note.7 to >4.0 pts
Good
Documents most
pertinent
examination
components.4 to >2.0 pts
Fair
Documents some
pertinent
examination
components.2 to >0 pts
Poor
Physical examination
cursory; misses
several pertinent
components.Diagnostic
Reasoning10 to >7.0 pts
Excellent
Assessment
consistent with prior
documentation.
Clear justification for
diagnosis. Notes all
secondary problems.
Cost effective when7 to >4.0 pts
Good
Assessment
consistent with
prior
documentation.
Clear justification
for diagnosis.
Notes most4 to >2.0 pts
Fair
Assessment mostly
consistent with prior
documentation. Fails
to clearly justify
diagnosis or note
secondary problems
or orders2 to >0 pts
Poor
Assessment not
consistent with prior
documentation. Fails
to clearly justify
diagnosis or note
secondary problems
or orders9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 3/5Criteria Ratings Pts20 pts10 pts5 ptsordering diagnostic
tests.secondary
problems.inappropriate
diagnostic tests.inappropriate
diagnostic tests.Treatment
Plan/Patient
Education20 to >15.0 pts
Excellent
Treatment 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 pts
Good
Treatment plan
addresses most
issues raised by
diagnoses.
Medications
prescribed are
appropriate but
include 1 or 2 error in
writing prescription.10 to >5.0 pts
Fair
Treatment plan fails
to address most
issues raised by
diagnoses.
Medications are
inappropriate or
include 3 or more
errors in writing
prescription.5 to >0 pts
Poor
Minimal
treatment plan
addressed.
Medications are
inappropriate or
poorly written
prescription.Patient Education /
Follow Up /
Reflection10 to >8.0 pts
Excellent
Patient 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 pts
Good
Patient 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 pts
Fair
Patient 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 pts
Poor
Minimal patient
education
addressed.
Follow up plan
is inappropriate
Reflection is
absent.Written Expression
and Formatting
English writing
standards: Correct
grammar,
mechanics, and
proper
punctuation.
Professional
language utilized5 pts
Excellent
Uses correct
grammar,
spelling, and
punctuation with
no errors.
Professional
language utilized.4 pts
Good
Contains a few (1-
2) grammar,
spelling, and
punctuation errors.
Contains a few
errors (1 or 2) in
professional
language use.2 pts
Fair
Contains several
(3-4) grammar,
spelling, and
punctuation errors.
Contains several
errors (3 -4) in
professional
language use.0 pts
Poor
Contains many (≥ 5)
grammar, spelling, and
punctuation errors that
interfere with the
reader’s understanding.
Contains many errors in
professional language
use.9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 4/5Total Points: 100Criteria Ratings Pts5 ptsScholarly
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 pts
Excellent
Contains
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 pts
Good
Contains
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 pts
Fair
Contains
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 pts
Poor
Contains no
parenthetical/in-text
citations and 0
evidenced based
references listed.
Clinical practice
guidelines are not
cited if applicable.9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 5/5WK9FocusedNote.docxIn clinical settings, patients often present with musculoskeletal conditions such as chronic back pain. Drugs are typically prescribed to help manage this type of pain for patients. There are many different pain medicines, and each one has benefits and risks. To add to the complexity, each patient may also have a slightly different response to a pain reliever. When over-the-counter medications do not address a patient’s pain, more powerful prescription pain relievers, such as opioids, can be effective but also sometimes have serious side effects. There is also a risk of addiction. More than 70,000 people died in 2017 from drug overdoses, and almost 68% involved a prescription or illicit opioid. Drug overdose deaths continue to increase in the United States (Centers for Disease Control and Prevention, n.d.).For the advanced practice nurse, these statistics highlight the need to effectively screen for, diagnose, and manage opioid use. It is essential to carefully observe and watch for signs of drug abuse during patient evaluations. Because not all musculoskeletal conditions require narcotics, a thorough patient evaluation will help to ensure the development of an appropriate treatment plan with patient safety in mind.This week, you will continue to engage with Meditrek, recording your clinical hours and patient encounters. You will also learn about evaluation and management of musculoskeletal conditions in the reading selections as well as conduct a patient evaluation of a patient from your practicum experience who has a musculoskeletal condition. Based on diagnostic and treatment options you identify for the patient, you will identify a primary diagnosis, as well as a treatment and management plan.ReferenceCenters for Disease Control and Prevention (n.d.).CDC’s response to the opioid overdose epidemic.https://www.cdc.gov/opioids/LEARNING OBJECTIVESStudents will:· Describe clinical hours and patient encounters· Formulate diagnoses for adult patients· Justify adult patient treatment options· Advocate health promotion and patient education strategies across the adult lifespan· Synthesize the assessment and diagnosis of health conditions for a clinical patient· Fowler, G. C. (2020).Pfenninger and Fowler’s procedures for primary care(4th ed.). Elsevier.· Chapter 174, “Shoulder Dislocations” (pp. 1163–1167)· Chapter 175, “Ankle and Foot Splinting, Casting, and Taping” (pp. 1168–1175)· Chapter 176, “Cast Immobilization and Upper Extremity Splinting” (pp. 1176–1185)· Chapter 177, “Knee Braces” (pp. 1186–1192)· Chapter 178, “Fracture Care” (pp. 1193–1211)· Chapter 180, “Joint and Soft Tissue Aspiration and Injection (Arthrocentesis)” (pp. 1221–1239)· Chapter 181, “Trigger-Point Injection” (pp. 1240–1244)· Chapter 235, “Principles of X-Ray Interpretation” (pp. 1566–1575)PRAC_6531_Episodic_Focused_Note_Template_Final1.docxMaster of Science in Nursing   PRAC 6531:Primary Care of Adults Across the Lifespan PracticumEpisodic/Focus Note TemplatePatient Information:Initials, Age, Sex, RaceS.CC(chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT “bad headache for 3 days”).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. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:Location: headOnset: 3 days agoCharacter: pounding, pressure around the eyes and templesAssociated signs and symptoms: nausea, vomiting, photophobia, phonophobiaTiming: after being on the computer all day at workExacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely betterSeverity: 7/10 pain scaleCurrent Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Allergies:include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance).PMHx: include immunization status (note date oflast tetanusfor all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes neededSoc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:General:Head:EENT: etc. You should list these in bullet format and document the systems in order from head to toe.Example of Complete ROS:GENERAL: No weight loss, fever, chills, weakness, or fatigue.HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.SKIN: No rash or itching.CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.RESPIRATORY: No shortness of breath, cough, or sputum.GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.HEMATOLOGIC: No anemia, bleeding, or bruising.LYMPHATICS: No enlarged nodes. No history of splenectomy.PSYCHIATRIC: No history of depression or anxiety.ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.ALLERGIES: No history of asthma, hives, eczema, or rhinitis.O.Physical exam: From head-to-toe, includewhat you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History.Do not use “WNL” or “normal.” You must describe what you see.Always document in head to toe format (i.e., General: Head: EENT: etc.).Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).A.Differential Diagnoses(list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.P.Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.Also included in this section is the reflection.The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).ReferencesYou are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.© 2020 Walden University 1Week9_Assignment2FocusedNote.pdfFor this Assignment, you will work with a patient with a
musculoskeletal condition that you examined during the
last three weeks. You will complete your third
Episodic/Focused Note Template Form for this course
where you will gather patient information, relevant
diagnostic and treatment information as well as reflect on
health promotion and disease prevention in light of
patient factors such as age, ethnic group, previous
medical history (PMH), socio-economic, cultural
background, etc. In this week’s Learning Resources,
please review 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.To prepare:Use the Episodic/Focused 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 based on musculoskeletal conditions. With
this patient in mind, address the following in a Focused Note: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 three 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?EPISODIC VISIT: MUSCULOSKELETAL
FOCUSED NOTERESOURCESBe sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.WEEKLY RESOURCES9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 1/5https://waldenu.instructure.com/courses/131456/files/9870301/downloadhttps://waldenu.instructure.com/courses/131456/modules/items/4993252PRAC_6531_Week9_Assignment2_RubricNote: Your Focused Note Assignment must be signed by Day 7 of Week 9.Submit your Episodic/Focused Note Assignment.(Note: You will submit two files, your Focused Note Assignment, and a Word document of
pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 9.)Before submitting your final assignment, you can check your draft for authenticity. To check your
draft, access the Turnitin Drafts from the Start Here area.1. To submit your completed assignment, save your Assignment
as WK9Assgn2_LastName_Firstinitial2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.BY DAY 7SUBMISSION INFORMATION9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 2/5Criteria Ratings Pts10 pts20 pts10 pts10 pts10 ptsOrganization of
Write-up10 to >6.0 pts
Excellent
All information
organized in logical
sequence; follows
acceptable format
and utilizes expected
headings.6 to >3.0 pts
Good
Information generally
organized in logical
sequence; follows
acceptable format
and utilizes expected
headings.3 to >0.0 pts
Fair
Errors in format;
information
intermittently
organized.
Headings are used
some of the time.0 pts
Poor
Errors in format;
information
disorganized.
Headings are not
used appropriately.Thoroughness of
History20 to >15.0 pts
Excellent
Thoroughly documents all
pertinent history
components for type of
note; includes critical as
well as supportive
information.15 to >11.0 pts
Good
Documents most
pertinent
examination
components.11 to >7.0 pts
Fair
Documents some
pertinent
examination
components.7 to >0 pts
Poor
Physical
examination
cursory; misses
several pertinent
components.History of Present
Illness10 to >6.0 pts
Excellent
Thoroughly 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 pts
Good
Documents at least
6 aspects of the HPI
and pertinent other
data relevant to chief
complaint. Includes
critical information.4 to >2.0 pts
Fair
Documents at least 4
aspects of HPI and
some data pertinent
to chief complaint.
Lacks some critical
information or
rambling in history.2 to >0 pts
Poor
Missing many
aspects of HPI
and pertinent
data. Critical
information
missing.Thoroughness of
Physical Exam10 to >7.0 pts
Excellent
Thoroughly documents
all pertinent
examination
components for type of
note.7 to >4.0 pts
Good
Documents most
pertinent
examination
components.4 to >2.0 pts
Fair
Documents some
pertinent
examination
components.2 to >0 pts
Poor
Physical examination
cursory; misses
several pertinent
components.Diagnostic
Reasoning10 to >7.0 pts
Excellent
Assessment
consistent with prior
documentation.
Clear justification for
diagnosis. Notes all
secondary problems.
Cost effective when7 to >4.0 pts
Good
Assessment
consistent with
prior
documentation.
Clear justification
for diagnosis.
Notes most4 to >2.0 pts
Fair
Assessment mostly
consistent with prior
documentation. Fails
to clearly justify
diagnosis or note
secondary problems
or orders2 to >0 pts
Poor
Assessment not
consistent with prior
documentation. Fails
to clearly justify
diagnosis or note
secondary problems
or orders9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 3/5Criteria Ratings Pts20 pts10 pts5 ptsordering diagnostic
tests.secondary
problems.inappropriate
diagnostic tests.inappropriate
diagnostic tests.Treatment
Plan/Patient
Education20 to >15.0 pts
Excellent
Treatment 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 pts
Good
Treatment plan
addresses most
issues raised by
diagnoses.
Medications
prescribed are
appropriate but
include 1 or 2 error in
writing prescription.10 to >5.0 pts
Fair
Treatment plan fails
to address most
issues raised by
diagnoses.
Medications are
inappropriate or
include 3 or more
errors in writing
prescription.5 to >0 pts
Poor
Minimal
treatment plan
addressed.
Medications are
inappropriate or
poorly written
prescription.Patient Education /
Follow Up /
Reflection10 to >8.0 pts
Excellent
Patient 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 pts
Good
Patient 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 pts
Fair
Patient 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 pts
Poor
Minimal patient
education
addressed.
Follow up plan
is inappropriate
Reflection is
absent.Written Expression
and Formatting
English writing
standards: Correct
grammar,
mechanics, and
proper
punctuation.
Professional
language utilized5 pts
Excellent
Uses correct
grammar,
spelling, and
punctuation with
no errors.
Professional
language utilized.4 pts
Good
Contains a few (1-
2) grammar,
spelling, and
punctuation errors.
Contains a few
errors (1 or 2) in
professional
language use.2 pts
Fair
Contains several
(3-4) grammar,
spelling, and
punctuation errors.
Contains several
errors (3 -4) in
professional
language use.0 pts
Poor
Contains many (≥ 5)
grammar, spelling, and
punctuation errors that
interfere with the
reader’s understanding.
Contains many errors in
professional language
use.9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 4/5Total Points: 100Criteria Ratings Pts5 ptsScholarly
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 pts
Excellent
Contains
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 pts
Good
Contains
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 pts
Fair
Contains
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 pts
Poor
Contains no
parenthetical/in-text
citations and 0
evidenced based
references listed.
Clinical practice
guidelines are not
cited if applicable.9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 5/5WK9FocusedNote.docxIn clinical settings, patients often present with musculoskeletal conditions such as chronic back pain. Drugs are typically prescribed to help manage this type of pain for patients. There are many different pain medicines, and each one has benefits and risks. To add to the complexity, each patient may also have a slightly different response to a pain reliever. When over-the-counter medications do not address a patient’s pain, more powerful prescription pain relievers, such as opioids, can be effective but also sometimes have serious side effects. There is also a risk of addiction. More than 70,000 people died in 2017 from drug overdoses, and almost 68% involved a prescription or illicit opioid. Drug overdose deaths continue to increase in the United States (Centers for Disease Control and Prevention, n.d.).For the advanced practice nurse, these statistics highlight the need to effectively screen for, diagnose, and manage opioid use. It is essential to carefully observe and watch for signs of drug abuse during patient evaluations. Because not all musculoskeletal conditions require narcotics, a thorough patient evaluation will help to ensure the development of an appropriate treatment plan with patient safety in mind.This week, you will continue to engage with Meditrek, recording your clinical hours and patient encounters. You will also learn about evaluation and management of musculoskeletal conditions in the reading selections as well as conduct a patient evaluation of a patient from your practicum experience who has a musculoskeletal condition. Based on diagnostic and treatment options you identify for the patient, you will identify a primary diagnosis, as well as a treatment and management plan.ReferenceCenters for Disease Control and Prevention (n.d.).CDC’s response to the opioid overdose epidemic.https://www.cdc.gov/opioids/LEARNING OBJECTIVESStudents will:· Describe clinical hours and patient encounters· Formulate diagnoses for adult patients· Justify adult patient treatment options· Advocate health promotion and patient education strategies across the adult lifespan· Synthesize the assessment and diagnosis of health conditions for a clinical patient· Fowler, G. C. (2020).Pfenninger and Fowler’s procedures for primary care(4th ed.). Elsevier.· Chapter 174, “Shoulder Dislocations” (pp. 1163–1167)· Chapter 175, “Ankle and Foot Splinting, Casting, and Taping” (pp. 1168–1175)· Chapter 176, “Cast Immobilization and Upper Extremity Splinting” (pp. 1176–1185)· Chapter 177, “Knee Braces” (pp. 1186–1192)· Chapter 178, “Fracture Care” (pp. 1193–1211)· Chapter 180, “Joint and Soft Tissue Aspiration and Injection (Arthrocentesis)” (pp. 1221–1239)· Chapter 181, “Trigger-Point Injection” (pp. 1240–1244)· Chapter 235, “Principles of X-Ray Interpretation” (pp. 1566–1575)PRAC_6531_Episodic_Focused_Note_Template_Final1.docxMaster of Science in Nursing   PRAC 6531:Primary Care of Adults Across the Lifespan PracticumEpisodic/Focus Note TemplatePatient Information:Initials, Age, Sex, RaceS.CC(chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT “bad headache for 3 days”).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. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:Location: headOnset: 3 days agoCharacter: pounding, pressure around the eyes and templesAssociated signs and symptoms: nausea, vomiting, photophobia, phonophobiaTiming: after being on the computer all day at workExacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely betterSeverity: 7/10 pain scaleCurrent Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Allergies:include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance).PMHx: include immunization status (note date oflast tetanusfor all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes neededSoc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:General:Head:EENT: etc. You should list these in bullet format and document the systems in order from head to toe.Example of Complete ROS:GENERAL: No weight loss, fever, chills, weakness, or fatigue.HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.SKIN: No rash or itching.CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.RESPIRATORY: No shortness of breath, cough, or sputum.GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.HEMATOLOGIC: No anemia, bleeding, or bruising.LYMPHATICS: No enlarged nodes. No history of splenectomy.PSYCHIATRIC: No history of depression or anxiety.ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.ALLERGIES: No history of asthma, hives, eczema, or rhinitis.O.Physical exam: From head-to-toe, includewhat you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History.Do not use “WNL” or “normal.” You must describe what you see.Always document in head to toe format (i.e., General: Head: EENT: etc.).Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).A.Differential Diagnoses(list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.P.Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.Also included in this section is the reflection.The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).ReferencesYou are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.© 2020 Walden University 1Week9_Assignment2FocusedNote.pdfFor this Assignment, you will work with a patient with a
musculoskeletal condition that you examined during the
last three weeks. You will complete your third
Episodic/Focused Note Template Form for this course
where you will gather patient information, relevant
diagnostic and treatment information as well as reflect on
health promotion and disease prevention in light of
patient factors such as age, ethnic group, previous
medical history (PMH), socio-economic, cultural
background, etc. In this week’s Learning Resources,
please review 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.To prepare:Use the Episodic/Focused 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 based on musculoskeletal conditions. With
this patient in mind, address the following in a Focused Note: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 three 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?EPISODIC VISIT: MUSCULOSKELETAL
FOCUSED NOTERESOURCESBe sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.WEEKLY RESOURCES9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 1/5https://waldenu.instructure.com/courses/131456/files/9870301/downloadhttps://waldenu.instructure.com/courses/131456/modules/items/4993252PRAC_6531_Week9_Assignment2_RubricNote: Your Focused Note Assignment must be signed by Day 7 of Week 9.Submit your Episodic/Focused Note Assignment.(Note: You will submit two files, your Focused Note Assignment, and a Word document of
pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 9.)Before submitting your final assignment, you can check your draft for authenticity. To check your
draft, access the Turnitin Drafts from the Start Here area.1. To submit your completed assignment, save your Assignment
as WK9Assgn2_LastName_Firstinitial2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.BY DAY 7SUBMISSION INFORMATION9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 2/5Criteria Ratings Pts10 pts20 pts10 pts10 pts10 ptsOrganization of
Write-up10 to >6.0 pts
Excellent
All information
organized in logical
sequence; follows
acceptable format
and utilizes expected
headings.6 to >3.0 pts
Good
Information generally
organized in logical
sequence; follows
acceptable format
and utilizes expected
headings.3 to >0.0 pts
Fair
Errors in format;
information
intermittently
organized.
Headings are used
some of the time.0 pts
Poor
Errors in format;
information
disorganized.
Headings are not
used appropriately.Thoroughness of
History20 to >15.0 pts
Excellent
Thoroughly documents all
pertinent history
components for type of
note; includes critical as
well as supportive
information.15 to >11.0 pts
Good
Documents most
pertinent
examination
components.11 to >7.0 pts
Fair
Documents some
pertinent
examination
components.7 to >0 pts
Poor
Physical
examination
cursory; misses
several pertinent
components.History of Present
Illness10 to >6.0 pts
Excellent
Thoroughly 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 pts
Good
Documents at least
6 aspects of the HPI
and pertinent other
data relevant to chief
complaint. Includes
critical information.4 to >2.0 pts
Fair
Documents at least 4
aspects of HPI and
some data pertinent
to chief complaint.
Lacks some critical
information or
rambling in history.2 to >0 pts
Poor
Missing many
aspects of HPI
and pertinent
data. Critical
information
missing.Thoroughness of
Physical Exam10 to >7.0 pts
Excellent
Thoroughly documents
all pertinent
examination
components for type of
note.7 to >4.0 pts
Good
Documents most
pertinent
examination
components.4 to >2.0 pts
Fair
Documents some
pertinent
examination
components.2 to >0 pts
Poor
Physical examination
cursory; misses
several pertinent
components.Diagnostic
Reasoning10 to >7.0 pts
Excellent
Assessment
consistent with prior
documentation.
Clear justification for
diagnosis. Notes all
secondary problems.
Cost effective when7 to >4.0 pts
Good
Assessment
consistent with
prior
documentation.
Clear justification
for diagnosis.
Notes most4 to >2.0 pts
Fair
Assessment mostly
consistent with prior
documentation. Fails
to clearly justify
diagnosis or note
secondary problems
or orders2 to >0 pts
Poor
Assessment not
consistent with prior
documentation. Fails
to clearly justify
diagnosis or note
secondary problems
or orders9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 3/5Criteria Ratings Pts20 pts10 pts5 ptsordering diagnostic
tests.secondary
problems.inappropriate
diagnostic tests.inappropriate
diagnostic tests.Treatment
Plan/Patient
Education20 to >15.0 pts
Excellent
Treatment 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 pts
Good
Treatment plan
addresses most
issues raised by
diagnoses.
Medications
prescribed are
appropriate but
include 1 or 2 error in
writing prescription.10 to >5.0 pts
Fair
Treatment plan fails
to address most
issues raised by
diagnoses.
Medications are
inappropriate or
include 3 or more
errors in writing
prescription.5 to >0 pts
Poor
Minimal
treatment plan
addressed.
Medications are
inappropriate or
poorly written
prescription.Patient Education /
Follow Up /
Reflection10 to >8.0 pts
Excellent
Patient 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 pts
Good
Patient 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 pts
Fair
Patient 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 pts
Poor
Minimal patient
education
addressed.
Follow up plan
is inappropriate
Reflection is
absent.Written Expression
and Formatting
English writing
standards: Correct
grammar,
mechanics, and
proper
punctuation.
Professional
language utilized5 pts
Excellent
Uses correct
grammar,
spelling, and
punctuation with
no errors.
Professional
language utilized.4 pts
Good
Contains a few (1-
2) grammar,
spelling, and
punctuation errors.
Contains a few
errors (1 or 2) in
professional
language use.2 pts
Fair
Contains several
(3-4) grammar,
spelling, and
punctuation errors.
Contains several
errors (3 -4) in
professional
language use.0 pts
Poor
Contains many (≥ 5)
grammar, spelling, and
punctuation errors that
interfere with the
reader’s understanding.
Contains many errors in
professional language
use.9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 4/5Total Points: 100Criteria Ratings Pts5 ptsScholarly
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 pts
Excellent
Contains
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 pts
Good
Contains
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 pts
Fair
Contains
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 pts
Poor
Contains no
parenthetical/in-text
citations and 0
evidenced based
references listed.
Clinical practice
guidelines are not
cited if applicable.9/23/24, 12:55 PM Week 9: Assignment 2https://waldenu.instructure.com/courses/131456/assignments/1637392?module_item_id=4993241 5/5123Bids(64)PROVEN STERLINGMiss DeannaDr. Ellen RMDr. Aylin JMDr. Sarah BlakeProf Double RSTELLAR GEEK A+Young NyanyaProWritingGurugrA+de plusDr. Adeline Zoefirstclass tutorDr M. MichelleTutor Cyrus KenDr. Sophie MilesWIZARD_KIMnicohwilliamPremiumMUSYOKIONES A+Isabella HarvardShow All Bidsother Questions(10)SQL AssignmentInformation Management 2Reflection Journal: Cost/Benefit of Sustaining LifeCaseNanoclay-Modified Asphalt in Civil Engineering 

1. For each topic from the list given above the following researches should be made:  

•…study case in HSA. Health care administrationFace-To-Face Interview (Financial Field)Paper of world ReligionsAstronomy – Properties of StarsWEEK 10 JOURNAL

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