Tina Jones Health Assessment|2025

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ASSESSMENT INFORMATION for students

Throughout your training we are committed to your learning by providing a training and assessment framework that ensures the knowledge gained through training is translated into practical on the job improvements.

You are going to be assessed for:

Your skills and knowledge using written and observation activities that apply to your workplace.

Your ability to apply your learning.

Your ability to recognise common principles and actively use these on the job.

All of your assessment and training is provided as a positive learning tool. Your assessor will guide your learning and provide feedback on your responses to the assessment materials until you have been deemed competent in this unit.

How you will be assessed

The process we follow is known as competency-based assessment. This means that evidence of your current skills and knowledge will be measured against national standards of best practice, not against the learning you have undertaken either recently or in the past. Some of the assessment will be concerned with how you apply your skills and knowledge in your workplace, and some in the training room as required by each unit.

The assessment tasks have been designed to enable you to demonstrate the required skills and knowledge and produce the critical evidence to successfully demonstrate competency at the required standard.

Your assessor will ensure that you are ready for assessment and will explain the assessment process. Your assessment tasks will outline the evidence to be collected and how it will be collected, for example; a written activity, case study, or demonstration and observation.

The assessor will also have determined if you have any special needs to be considered during assessment. Changes can be made to the way assessment is undertaken to account for special needs and this is called making Reasonable Adjustment.

 

What happens if your result is ‘Not Yet Competent’ for one or more assessment tasks?

Our assessment process is designed to answer the question “has the desired learning outcome been achieved yet?” If the answer is “Not yet”, then we work with you to see how we can get there.

In the case that one or more of your assessments has been marked ‘NYC’, your trainer will provide you with the necessary feedback and guidance, in order for you to resubmit your responses.

 

What if you disagree on the assessment outcome?

You can appeal against a decision made in regards to your assessment. An appeal should only be made if you have been assessed as ‘Not Yet Competent’ against a specific unit and you feel you have sufficient grounds to believe that you are entitled to be assessed as competent. You must be able to adequately demonstrate that you have the skills and experience to be able to meet the requirements of units you are appealing the assessment of.

Your trainer will outline the appeals process, which is available to the student. You can request a form to make an appeal and submit it to your trainer, the course coordinator, or the administration officer. The RTO will examine the appeal and you will be advised of the outcome within 14 days. Any additional information you wish to provide may be attached to the appeal form.

 

What if I believe I am already competent before training?

If you believe you already have the knowledge and skills to be able to demonstrate competence in this unit, speak with your trainer, as you may be able to apply for Recognition of Prior Learning (RPL).

 

Assessor Responsibilities

Assessors need to be aware of their responsibilities and carry them out appropriately. To do this they need to:

Ensure that participants are assessed fairly based on the outcome of the language, literacy and numeracy review completed at enrolment.

Ensure that all documentation is signed by the student, trainer, workplace supervisor and assessor when units and certificates are complete, to ensure that there is no follow-up required from an administration perspective.

Ensure that their own qualifications are current.

When required, request the manager or supervisor to determine that the student is ‘satisfactorily’ demonstrating the requirements for each unit. ‘Satisfactorily’ means consistently meeting the standard expected from an experienced operator.

When required, ensure supervisors and students sign off on third party assessment forms or third party report.

Follow the recommendations from moderation and validation meetings.

How should I format my assessments?

Your assessments should be typed in a 11 or 12 size font for ease of reading. You must include a footer on each page with the student name, unit code and date. Your assessment needs to be submitted as a hardcopy or electronic copy as requested by your trainer.

 

How long should my answers be?

The length of your answers will be guided by the description in each assessment, for example:

Type of Answer Answer Guidelines

 
Short Answer 4 typed lines = 50 words, or

5 lines of handwritten text
Long Answer 8 typed lines = 100 words, or

10 lines of handwritten text = of a foolscap page
Brief Report 500 words = 1 page typed report, or

50 lines of handwritten text = 1foolscap handwritten pages
Mid Report 1,000 words = 2 page typed report

100 lines of handwritten text = 3 foolscap handwritten pages
Long Report 2,000 words = 4 page typed report

200 lines of handwritten text = 6 foolscap handwritten pages

 

How should I reference the sources of information I use in my assessments?

Include a reference list at the end of your work on a separate page. You should reference the sources you have used in your assessments in the Harvard Style. For example:

Website Name – Page or Document Name, Retrieved insert the date. Webpage link.

For a book: Author surname, author initial Year of publication, Title of book, Publisher, City, State

 

assessment guide

The following table shows you how to achieve a satisfactory result against the criteria for each type of assessment task.

Assessment Method Satisfactory Result Non-Satisfactory Result
You will receive an overall result of Competent or Not Yet Competent for the unit. The assessment process is made up of a number of assessment methods. You are required to achieve a satisfactory result in each of these to be deemed competent overall. Your assessment may include the following assessment types.
Questions All questions answered correctly Incorrect answers for one or more questions
  Answers address the question in full; referring to appropriate sources from your workbook and/or workplace Answers do not address the question in full. Does not refer to appropriate or correct sources.
Third Party Report Supervisor or manager observes work performance and confirms that you consistently meet the standards expected from an experienced operator Could not demonstrate consistency. Could not demonstrate the ability to achieve the required standard
Written Activity The assessor will mark the activity against the detailed guidelines/instructions Does not follow guidelines/instructions
  Attachments if requested are attached Requested supplementary items are not attached
  All requirements of the written activity are addressed/covered. Response does not address the requirements in full; is missing a response for one or more areas.
  Responses must refer to appropriate sources from your workbook and/or workplace One or more of the requirements are answered incorrectly.

Does not refer to or utilise appropriate or correct sources of information
Observation All elements, criteria, knowledge and performance evidence and critical aspects of evidence, are demonstrated at the appropriate AQF level Could not demonstrate elements, criteria, knowledge and performance evidence and/or critical aspects of evidence, at the appropriate AQF level
Case Study All comprehension questions answered correctly; demonstrating an application of knowledge of the topic case study. Lack of demonstrated comprehension of the underpinning knowledge (remove) required to complete the case study questions correctly. One or more questions are answered incorrectly.
  Answers address the question in full; referring to appropriate sources from your workbook and/or workplace Answers do not address the question in full; do not refer to appropriate sources.

 

Assessment Cover Sheet
Student’s name:  
Assessors Name:   Date:
Is the Student ready for assessment? Yes No
Has the assessment process been explained? Yes No
Does the Student understand which evidence is to be collected and how? Yes No
Have the Student’s rights and the appeal system been fully explained? Yes No
Have you discussed any special needs to be considered during assessment? Yes No
The following documents must be completed and attached
Written Activity Checklist

The student will complete the written activity provided to them by the assessor.

The Written Activity Checklist will be completed by the assessor.

 S NYS
Observation / Demonstration

The student will demonstrate a range of skills and the assessor will observe where appropriate to the unit.

The Observation Checklist will be completed by the assessor.

 S NYS
Questioning Checklist

The student will answer a range of questions either verbally or written.

The Questioning Checklist will be completed by the assessor.

 S NYS
I agree to undertake assessment in the knowledge that information gathered will only be used for professional development purposes and can only be accessed by the RTO:
Overall Outcome Competent Not yet Competent
Student Signature: Date:
Assessor Signature: Date:

Assessment cover sheet

 

written activity

1. For this task you are to write an information guide for new employees about communicating effectively in the health and community services industry. In your guide you will need to include information on the following topics:

a. Effectively communicating with people

 

 

b. Collaborating with colleagues

 

 

c. Constraints to communication and strategies to address them

 

 

d. Reporting problems identified in work activities

 

 

e. Workplace correspondence and documentation requirements

 

 

f. Continuous improvement participation

 

 

2. For this task you must research each of the following topics, and complete a basic report on your findings. To guide your research please answer the following questions:

a. When communicating with others in the community sector what legislation and ethical consideration need to be made?

 

 

b. Where might you locate information on the application of legal and ethical aspects of health and community services work?

 

 

c. How can you ensure you make ethical decisions at all times?

 

 

d. What is the difference between motivational interviewing and coercive approach?

 

 

e. What is the difference between collaboration and confrontation?

 

 

f. What are the influences on communication?

 

 

g. Why is grammar, speed and pronunciation for verbal communication important?

 

 

h. Why is non-verbal communication important to use and recognise?

 

 

i. Choose a community service organisation that you are familiar with and discuss the structure, function and interrelationships they have.

 

 

j. What digital media is often used in the community service sector and how is it used?

 

 

 

 

Questions

The following questions may be answered verbally with your assessor or you may write down your answers. Please discuss this with your assessor before you commence. Short Answers are required which is approximately 4 typed lines = 50 words, or 5 lines of handwritten text.

Your assessor will take down dot points as a minimum if you choose to answer them verbally.

Answer the following questions either verbally with your assessor or in writing.

1. What are the different categories of communication?

 

 

 

2. What can you do to communicate effectively with people?

 

 

3. Write two examples each of open questions and closed questions.

 

 

 

 

4. What can you do to collaborate with colleagues effectively?

 

 

 

 

5. List six examples of industry terminology that you would use in verbal, written and digital communications.

 

 

6. What can you do to address communication constraints?

 

 

7. Discuss two strategies to handle conflict and maintain a tension-free workplace.

 

 

8. What are two pieces of legislation, regulations or Acts do you need to comply with in community services?

 

 

9. Who should you report any unresolved conflicts, breach or non-adherence to standard operating procedures, or any issues impacting on the rights of you or your client to?

 

 

10. How would you promote and model changes in the workplace?

 

 

11. List six different types of documentation you may need to complete to organisational standards in your workplace.

 

 

12. How can you contribute to continuous improvement in your workplace?

 

 

13. Who can you seek advice from in relation to improving your skills and knowledge?

 

 

14. Who would you speak to in relation to accessing options for skills development and training?

 

 

15. Define each of the following:

a. Privacy, confidentiality and disclosure

b. Discrimination

c. Duty of care

d. Mandatory reporting

e. Translation

f. Informed consent

g. Work role boundaries – responsibilities and limitations

h. Child protection across all health and community services contexts, including duty of care when child is not the client, indicators of risk and adult disclosure

 

 

16. Discuss the following two techniques in relation to communication:

a. Reflecting

b. Summarising

 

 

17. What is the difference between collaboration and confrontation?

 

 

18. What are the potential constraints to effective communication?

 

 

Developed by Enhance Your Future Pty Ltd 4 CHCCOM005 Communicate and work in health or community services Version 2 Course code and name

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Tina Jones Health Assessment|2025

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Name:

Section:

 

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

 

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

 

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

 

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To 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:

Musculoskeletal:

Psychiatric:

Neurological:

Skin:

Hematologic:

Endocrine:

 

 

 

© 2021 Walden University Page 1 of 1

 

 

 

© 20

21

 

Walden University

 

 

Page

1

 

of

2

 

 

 

Name:

 

Section:

 

 

Week 4

 

Shadow Health Digital Clinical Experience Health History Documentation

 

 

SUBJECTIVE DATA:

Include what the patient tells you, but organize the information.

 

 

Chief Complaint (CC):

 

History of Present Illness

(HPI):

 

Medications:

 

Allergies:

 

Past Medical History (PMH):

 

Past Surgical History (PSH):

 

Sexual/Reproductive History:

 

Personal/Social History:

 

Immunization History:

 

Health Maintenance:

 

Significant Family History (

Include history of parents,

maternal/p

aternal

Grandparents, siblings,

and children):

 

 

Review of Systems:

From head

–

to

–

toe, include each system that covers the Chief Complaint,

History of Present Illness, and History).

 

Remember that the information you include in this

section is based on what t

he patient tells you. To 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:

 

 

© 2021 Walden University Page 1 of 2

 

 

Name:

Section:

 

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

 

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

 

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings,

and children):

 

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,

History of Present Illness, and History). Remember that the information you include in this

section is based on what the patient tells you. To 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:

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Academic Success and Professional Development Plan Part 6|2025

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At some point in every construction project, efforts turn from design and the focus moves to actual construction. With the vision in place and the tools secured, the blueprint can be finalized and approved. Then it is time to put on hardhats and begin work.

Throughout the course you have developed aspects of your Academic and Professional Development Plan. You have thought a great deal about your vision and goals, your academic and professional network of support, research strategies and other tools you will need, the integrity of your work, and the value of consulting the work of others. With your portfolio in place, it is now time to finalize your blueprint for success.

Much as builders remain cognizant of the building standards as they plan and begin construction, nurses must remain mindful of the formal standards of practice that govern their specialties. A good understanding of these standards can help ensure that your success plan includes any steps necessary to excel within your chosen specialty.

In this Assignment you will continue developing your Academic Success and Professional Development Plan by developing the final component–a review of your specialty standards of practice. You will also submit your final version of the document, including Parts 1–5.

To Prepare:

  • Review the standards of practice related to your chosen specialty- Psychiatric Mental Health Nurse practitioner.
  • Download the Nursing Specialty Comparison Matrix.
  • Examine professional organizations related to the specialization you have chosen and identify at least one to focus on for this Assignment.
  • Reflect on the thoughts you shared in the Discussion forum regarding your choice of a specialty, any challenges you have encountered in making this choice, and any feedback you have received from colleagues in the Discussion.

The Assignment:
Complete the following items and incorporate them into the final version of your Academic Success and Professional Development Plan.

  • Complete the Nursing Specialty Comparison Matrix, comparing at least two nursing specialties that include your selected specialization and second-preferred specialization- Selected specialization is Psychiatric mental health nurse practitioner and the second -preferred specialization is Family nurse practitioner.
  • Write a 2- to 3-paragraph justification statement identifying your reasons for choosing your MSN specialization. Incorporate feedback you received from colleagues in this Module’s Discussion forum.
  • Identify the professional organization related to your chosen specialization for this Assignment, and explain how you can become an active member of this organization.    – American psychiatric nurses association.

Note: Your final version of the Academic Success and Professional Development Plan should include all components as presented the Academic Success and Professional Development Plan template.

Complete the following items and incorporate them into the final version of your Academic Success and Professional Development Plan:

·   Complete the Nursing Specialty Comparison Matrix comparing at least two nursing specialties, including your selected specialization and second-preferred specialization.

·   Write a 2-3 paragraph justification statement identifying your reasons for choosing your MSN specialization. Incorporate feedback you received from colleagues in this week’s Discussion Forum.

·   Identify the professional organization related to the specialization you have chosen to focus on for this Assignment and explain how you can become an active member of this organization.–

Levels of Achievement:  Excellent 77 (77%) – 85 (85%)    Good 68 (68%) – 76 (76%)    Fair 59 (59%) – 67 (67%)    Poor 0 (0%) – 58 (58%)

Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance.  A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria.–

Levels of Achievement:  Excellent 5 (5%) – 5 (5%)    Good 4 (4%) – 4 (4%)    Fair 3.5 (3.5%) – 3.5 (3.5%)    Poor 0 (0%) – 3 (3%)

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–

Levels of Achievement:  Excellent 5 (5%) – 5 (5%)    Good 4 (4%) – 4 (4%)    Fair 3.5 (3.5%) – 3.5 (3.5%)    Poor 0 (0%) – 3 (3%)

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.–

Levels of Achievement:  Excellent 5 (5%) – 5 (5%)    Good 4 (4%) – 4 (4%)    Fair 3.5 (3.5%) – 3.5 (3.5%)    Poor 0 (0%) – 3 (3%)

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characteristics would lead a provider to suspect domestic violence|2025

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 Topic 5 DQ 2

What characteristics would lead a provider to suspect domestic violence, child abuse, or elder abuse is taking place within a family? Discuss your facility’s procedure for reporting these types of abuse.

Violence and abuse is described as any intentional physical, mental, or psychological harm inflicted on a vulnerable person. This includes punching, berating, screaming, and other types of intentional cruelty. Domestic violence also involves threats or mild verbal or physical attacks, and victims seek to comply with the abuser’s demands. Victims feel trapped, reliant, helpless, and powerless. They can experience depression as a result of being stuck in the abuser’s power and control loop. As a victim’s self-esteem deteriorates as a result of prolonged abuse, he or she will blame themselves for the violence and be unable to see a way out of the situation. Neglect is described as any deliberate or unintentional lack of concern for someone’s well-being, such as failing to meet a dependent’s basic needs. Child abuse, child neglect, dependent adult abuse, dependent adult neglect, and domestic violence are all examples of abuse and neglect

If a family member shows apparent signs of bruising, malnutrition, depression, extreme fear, extortion, or other similar factors, a mandatory leader can suspect violence or neglect. However, this list is little and not an exhaustive, and other elements which exist. There is no one-size-fits-all solution, but mandatory reporters are expected to search for trends of concern and various indicators of problems; they are expected to ask questions if required and to report anything they believe, even if they are not 100 percent certain.

A instructor, for example, can suspect child abuse if a student is chronically underweight and seems desperate to eat all they can while at school. If a woman arrives at the emergency room with severe bruises and physical injuries that do not seem to match her reasons for the medical problems, a nurse may suspect domestic abuse. A mental health professional may suspect elder abuse if a senior citizen pays large sums of money to a single person or if a family member micromanages their finances.

A required reporter must be aware of the appropriate authority to which the alleged violence and neglect should be reported. In the case of child violence, each state has a department of child services (also known as social services) that should be contacted through the appropriate channels, such as hot lines. Domestic abuse should be reported to local law enforcement. Adult services agencies in each state deal with elder abuse and other forms of maltreatment of dependent adult.

References

Child abuse – reporting procedures. (2019). Better Health Channel. https://www.betterhealth.vic.gov.au/health/healthyliving/child-abuse-reporting-procedures

Elder abuse: Types, signs, and reporting. (2020, June 11). Find Assisted Living, Memory Care and Senior Living | A Place for Mom. https://www.aplaceformom.com/caregiver-resources/articles/elder-abuse

Respond to the post in discussion using 200-300 words in APA format with reference to support the post.

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the role of the community health nurse

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  1 DQ 1

Population health promotion involves the improvement of the quality of life of the community through the provision of primary, secondary and tertiary healthcare services. The community health nurse should, therefore, play a supervisory role of the community member to control and regulate their health behavior. The primary function of the nurse in the partnership with the community stakeholders is to guide and advise them on the healthy practice that can promote a healthy living of the community (Eldredge et al., 2015).

For instance, the community health nurse can decide to encourage the community stakeholders to champion the construction of toilets by each household in the community. That way, the nurse will be providing primary care through the community stakeholders who can prevent the development of disease in the community. The nurse can also take advantage of the community stakeholders to organize a community meeting whereby the nurse can advise and educate the community on health-seeking behavior and health promotion activities.

Appraising community resources like religious and nonprofit making organizations in the community is vital in enhancing community participation in health promotion. For instance, religious institutions are against some social acts that can encourage the spread of diseases like premarital sex. Appraising such values in such institutions helps to improve the community’s understanding and participation in disease prevention and health promotion.

Using 200-300 words APA format with references in support of the discussion

Explain the role of the community health nurse in partnership with community stakeholders for population health promotion. Explain why it is important to appraise community resources (nonprofit, spiritual/religious, etc.) as part of a community assessment and why these resources are important in population health promotion.

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how geopolitical and phenomenological place influence the context of a population|2025

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  Topic 1 DQ 2

Geopolitical and phenomenological place influence the context of a population or community assessment and intervention in various ways. A community could be defined by one of two designations, phenomenological (relational) or geological (spatial). A geographic community is a community within defined jurisdictional boundaries. These communities could include city communities, rural municipalities or towns. Phenomenological communities, on the other hand, define a group of people with shared or similar-minded relationships, beliefs, goals, and interests (Leipert, 1996). They might not necessarily share the same geographical boundaries as geographical communities. These communities could include social groups or religious groups. These people mostly come together to achieve the feeling of belonging in their relational designations. These people may have a group perspective that differentiates them from other groups on matters including culture, values, beliefs, characteristics, and goals.

Everyone lives in a geographic community and many people are also part of a phenomenological group. These groupings present various challenges for public health nurses. The main challenge is the issue of cultural and language barriers. Some of the practices that can help overcome these challenges include reflective practice and obtaining knowledge of different cultures and practices. Nurses should also self-evaluate and ensure that their personal beliefs do not interfere with the nursing process.

The nursing process is utilized to assist in identifying health issues because it involves the appropriate application of a systematic series of actions that aim at ensuring that individuals achieve their optimal level of health. The main steps in the nursing processes include assessment, diagnosis, planning, implementation, and evaluation. Assessment refers to the collection and evaluation of information regarding the status of health in the community (Rector, 2013). It aids in discovering potential or existing needs and assets as a basis for any future action plans or interventions.

Using 200-300 words APA format with references to support the discussion.

Discuss how geopolitical and phenomenological place influence the context of a population or community assessment and intervention. Describe how the nursing process is utilized to assist in identifying health issues (local or global in nature) and in creating an appropriate intervention, including screenings and referrals, for the community or population.

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Research Critiques and PICOT Statement Final Draft

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Prepare this assignment as a 1,500-1,750 word paper using the instructor feedback from the Topic 1, 2, and 3 assignments and the guidelines below.

 

PICOT Statement 

Revise the PICOT statement you wrote in the Topic 1 assignment.

 

Research Critiques

In the Topic 2 and Topic 3 assignments you completed a qualitative and quantitative research critique. Use the feedback you received from your instructor on these assignments to finalize the critical analysis of the study by making appropriate revisions.

The completed analysis should connect to your identified practice problem of interest that is the basis for your PICOT statement.

Refer to “Research Critique Guidelines.” Questions under each heading should be addressed as a narrative in the structure of a formal paper.

 

Proposed Evidence-Based Practice Change

Discuss the link between the PICOT statement, the research articles, and the nursing practice problem you identified. Include relevant details and supporting explanation and use that information to propose evidence-based practice changes.

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

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. Please refer to the directions in the Student Success Center.

NRS-433V-RS-Research-Critique-Guidelines.docx

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how the concept of health has changed overtime|2025

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In the nineteenth century, health was described as the absence of disease.Because of the lack of sanitary conditions, diseases spread more widely.Sanitary conditions were better known in the late 19th and early 20th centuries, and steps were taken to adequately control them, resulting in diseases that were more manageable. Vaccines were invented in the twentieth century, and the concept of health changed from cure to prevention. As the field of health promotion expanded, the term “health” came to mean a combination of factors such as physical, emotional, and spiritual well-being (Falkner, 2018). Today’s goals is to create a community of wellness in which health promotion and disease prevention take precedence over seeking careonce an illness has developed.We now realize that fitness and wellbeing go hand in hand with disease prevention. We may not always have control over our health, but we can make decisions to improve our well-being.

Promoting good health has existed for as long as there have been efforts to improve the public’s health. “The method of encouraging people to gain control over and improve their health is known as health promotion” (World Health Organization, 2019, para. 1).It shifts the emphasis away from human actions and toward a variety of social and environmental interventions.The nurse’s position in health promotion is critical, and it includes being an advocate, a provider of care/services, a care manager, an educator, and a researcher. The nurse is pushing reform to strengthen procedures in order to improve patient safety by using EBP to do so.

Falkner, A. (2018) Health promotion in nursing care. In Grand Canyon University (Eds.), Health promotion: Health and wellness across the continuum. Retrieved from

World Health Organization. (2019). What is health promotion. Retrieved from https://www.who.int/healthpromotion/fact-sheet/e

Respond using 200-300 words APA format with references supporting in discussion

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Scientific Paradigms

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Write a 195-word message in which you discuss:

1-Why are both paradigms important to the development of nursing science?

2-How do the authors justify having an alternative hierarchy of evidence for nursing, as contrasted with medicine (pp. 24–26, Types of Evidence and Evidence Hierarchies, Ch. 2, Nursing Research)?

Read instructions: ( used attached documents to write the word message discussion. Stay on topic given on the 2 questions above. all information needed is been attached. thank you. )

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Soap Note 1 Acute Conditions

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Soap Note 1 Acute Conditions

Soap Note 1 Acute Conditions (15 Points) Due 06/15/2019

Pick any Acute Disease from Weeks 1-5 (see syllabus)

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions

Follow the MRU Soap Note Rubric as a guide:

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts)

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: __________________________________

1 sample  SAMPLE Block format Soap Note Template.docx

SOAP NOTE SAMPLE FORMAT FOR MRC

 

Name:  LP

Date:

Time: 1315

 

Age: 30

Sex: F

 

SUBJECTIVE

 

CC:  

“I am having vaginal itching and pain in   my lower abdomen.”

 

HPI:  

Pt is a   30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after   unsuccessful self-treatment of vaginal itching, burning upon urination, and   lower abdominal pain. She is concerned   for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with   urination has been present for 3 weeks, and the abdominal pain has been   intermittent since months ago. Pt has   tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms,   including urgency or frequency. She   describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10   at times. 200mg of PO Advil PRN   reduces the pain to a 7/10. Pt denies   any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but   denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any   vaginal irritants. She reports that   she is in a stable sexual relationship, and denies any new sexual partners in   the last 90 days. She denies any   recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well   as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also   takes Advil for. She reports her last   PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP   smear result. Pt denies any hx of   pregnancies. Other medical hx includes   GERD. She reports that she has an Rx   for Protonix, but she does not take it every day. Her family hx includes the presence of DM   and HTN.

 

Current Medications: 

Protonix   40mg PO Daily for GERD

MTV OTC   PO Daily

Advil   200mg OTC PO PRN for pain

 

PMHx:

Allergies: 

NKA & NKDA

Medication Intolerances: 

Denies

Chronic Illnesses/Major traumas

GERD

Hospitalizations/Surgeries

Denies

 

Family History

Father-   DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal   grandparents without known medical issues; 1 brother and 3 other sisters   without known medical issues; No children.

 

Social History

Lives   alone. Currently in a stable sexual   relationship with one man. Works for   DEFACS. Reports occasional alcohol   use, but denies tobacco or illicit drug use.

 

ROS

 

General 

Denies   weight change, fatigue, fever, night sweats

Cardiovascular

Denies   chest pain and edema. Reports rare palpitations that are relieved by drinking   water

 

Skin

Denies   any wounds, rashes, bruising, bleeding or skin discolorations, any changes in   lesions

Respiratory

Denies   cough. Reports dyspnea that accompanies the rare palpitations and is also   relieved by drinking water

 

Eyes

Denies corrective   lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal   pain (see HPI) and Hx of GERD. Denies   N/V/D, constipation, appetite changes

 

Ears

Denies   Ear pain, hearing loss, ringing in ears

Genitourinary/Gynecological

Reports   burning with urination, but denies frequency or urgency. Contraceptive and STD prevention includes   condoms with every coital event. Current stable sexual relationship with one man. Denies known historic or recent STD   exposure. Last PAP was 7/2016 and normal. Regular monthly menstrual cycle   lasting 3-4 days.

 

Nose/Mouth/Throat

Denies   sinus problems, dysphagia, nose bleeds or discharge

Musculoskeletal

Denies   back pain, joint swelling, stiffness or pain

 

Breast

Denies   SBE

Neurological

Denies syncope,   seizures, paralysis, weakness

 

Heme/Lymph/Endo

Denies   bruising, night sweats, swollen glands

Psychiatric

Denies   depression, anxiety, sleeping difficulties

 

OBJECTIVE

 

Weight   140lb

Temp -97.7

BP 123/82

 

Height 5’4”

Pulse 74

Respiration 18

 

General Appearance

Healthy   appearing adult female in no acute distress. Alert and oriented; answers   questions appropriately.

 

Skin

Skin is   normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions   noted.

 

HEENT

Head is   norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in   good repair.

 

Cardiovascular

S1, S2   with regular rate and rhythm. No extra heart sounds.

 

Respiratory

Symmetric   chest walls. Respirations regular and easy; lungs clear to auscultation   bilaterally.

 

Gastrointestinal

Abdomen   flat; BS active in all 4 quadrants. Abdomen soft, suprapubic   tender. No hepatosplenomegaly.

 

Genitourinary

Suprapubic   tenderness noted. Skin color normal   for ethnicity. Irritation noted at   labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes   not palpable. Vagina pink and moist   without lesions. Discharge minimal,   thick, dark red, no odor. Cervix pink   without lesions. No CMT. Uterus normal size, shape, and consistency.

 

Musculoskeletal

Full   ROM seen in all 4 extremities as patient moved about the exam room.

 

Neurological 

Speech   clear. Good tone. Posture erect. Balance stable; gait normal.

 

Psychiatric

Alert   and oriented. Dressed in clean clothes. Maintains eye contact. Answers   questions appropriately.

 

Lab Tests

Urinalysis   – blood noted (pt. on menstrual period), but results negative for infection

Urine   culture testing unavailable

Wet   prep – inconclusive

STD   testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B   & C

 

Special Tests- No ordered at this   time.

 

Diagnosis 

 

Differential Diagnoses

  • 1-Bacterial Vaginosis (N76.0)
  • 2- Malignant neoplasm of female genital organ,         unspecified. (C57.9)
  • 3-Gonococcal infection, unspecified. (A54.9)

Diagnosis

o Urinary   tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina.   (B37.3) secondary to presenting symptoms (Colgan & Williams, 2011) & (Hainer   & Gibson, 2011).

 

Plan/Therapeutics

 

  • Plan:
    • Medication –

§ Terconazole cream 1 vaginal application QHS for 7 days for   Vulvovaginal Candidiasis;

§ Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days   for UTI (Woo & Wynne, 2012)

  • Education –

§ Medications prescribed.

§ UTI and Candidiasis symptoms, causes, risks, treatment,   prevention. Reasons to seek emergent care, including N/V, fever, or back   pain.

§ STD risks and preventions.

§ Ulcer prevention, including taking Protonix as prescribed,   not exceeding the recommended dose limit of NSAIDs, and not taking NSAIDs on   an empty stomach.

  • Follow-up         –

§ Pt will be contacted with results of STD studies.

§ Return to clinic when finished the period for perform   pap-smear or if symptoms do not resolve with prescribed TX.

 

References

Colgan, R. & Williams, M. (2011). Diagnosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84(7), 771-776.

Hainer, B. & Gibson, M. (2011). Vaginitis: Diagnosis and Treatment. American Family Physician, 83(7), 807-815.

Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers (3rd ed.). Philadelphia, PA: F.A. Davis Company.

2 sample Sample Regular Soap Note Template.docx

PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

SUBJECTIVE:

Chief complain: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.

Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

Respiratory: Patient denies shortness of breath, cough or hemoptysis.

Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.

General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed.

Differential diagnosis:

Ø Renal artery stenosis (ICD10 I70.1)

Ø Chronic kidney disease (ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease.

These basic laboratory tests are:

· CMP

· Complete blood count

· Lipid profile

· Thyroid-stimulating hormone

· Urinalysis

· Electrocardiogram

Ø Pharmacological treatment: 

The treatment of choice in this case would be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

Ø Non-Pharmacologic treatment:

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP

· Instruction about medication intake compliance.

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.

· No referrals needed at this time.

References

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0

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