The purpose of ts assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases. 1. Select a patient encounter from your current clinical experience. 2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, ts assignment may not be completed for a ‘general health, well cld, well woman, routine OB, routine physical exam (etc.)’ type of encounter. You will need to identify wch patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper. 3. For ts assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct ts assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual. Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date. Follow APA guidelines for running head on page 2 and subsequent pages. cef complaint – What are they being seen for? Ts is the reason that the patient sought care, stated in their own words, or paraphrased. story of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary] past medical story – Ts should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical story. Include dates if possible. State the offending medication/food and the reactions. Names, dosages, and routes of administration. Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. Click on the link below to explore the CDC’s information on the ‘social determinants of health’. Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. Ts should reflect what the patient is presently doing regarding the guidelines. Click on the link below to access information about current guidelines. ts is to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored wle discussing the story of present illness. You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. Wle the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/categories applicable to your patient’s cef complaint. General: May include if patient has had a fever, clls, fatigue, malaise, etc. Skin: HEENT: head, eyes, ears, nose and throat Neck: CV: cardiovascular Lungs: GI: gastrointestinal GU: genito-urinary PV: peripheral vascular MSK: musculoskeletal Neuro: neurological Endo: endocrine Psych: either limited for a focused exam or more extensive for a complete story and physical assessment. Ts area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs. Wle the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/assessments applicable to your patient’s cef complaint. Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory. VS: vital signs, height and weight, BMI Gen: general statement of appearance, if there is any acute distress. Skin: HEENT: head, eyes, ears, nose and throat Neck: CV: cardiovascular Lungs: Abd: abdomen GU: genito-urinary PV: peripheral vascular MSK: musculoskeletal Neuro: neurological exam Psych: Ts area is for tests that were that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.). (number each diagnosis) Start with the presenting cef complaint diagnosis first. Number each diagnosis. A statement of current condition of all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the S and O must support ts diagnosis. Pertinent positives and negatives must be found in the write-up. (number each plan specific to each diagnosis) These are the interventions that relate to the above diagnosis and address the following aspects (they should be separated out as listed below): labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s cef complaint. changes in meds, skin care, counseling information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling. referrals, or consult wle in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. The next section summarizes your critical tnking, decision-making and diagnostic reasoning skills that provides you the platform to expand on your identified Typhon patient encounter. It is a reflection of the thought process you used in caring for the patient. Follow the directions under each section and . All information should be in your own words. : Include information in regard to the pathophysiology related to the main diagnosis or illness process. Ts will help to understand how the S and O supported the diagnosis you assigned. Do not copy and paste from credible sources. Paraphrase source information as you construct your discussion of the pathophysiology and ensure that you provide in-text and reference citations for the source. (*** ): Choose one drug that was prescribed at ts visit or that is taken chronically by the patient to review. Please include the name of the drug (generic and brand), class, action, excretion, side effects and interactions, why ts particular drug is being prescribed for ts particular patient, what is ts drug intended to treat, (specifically antibiotics, what organisms are we treating?). What other drug could be chosen instead that would work, if any? Keep in mind the cost and convenience for the patient. Since the patient encounter you select for ts assignment is supposed to be one of the most complex encounters you have with ts course population, the likelihood exists that you will have a pharmacologic agent to discuss for ts assignment requirement. However, if there are no pharmacologic agents to utilize then choose a non-pharmacologic element of the therapeutic plan (e.g. ts could be hyperbaric therapy, water therapy, relaxation training, biofeedback, PT, OT, Counseling [e. g. nutritional, emotional, behavior modification, etc.]or a Complementary Alternative Medical regimen [e.g. nutritional therapy, a spiritual intervention, Emotional Freedom Therapy (EFT), journaling, visual imagery, progressive relaxation, Cranial Electrical Stimulation (CES), etc.] Do not copy and paste from credible sources. Paraphrase source information as you construct your discussion and ensure that you provide in-text and reference citations for the source. : Include in ts section: Include a list of all of the diagnoses you considered for your list of ‘differential diagnoses. Ts list may extend beyond the diagnoses identified in the ‘A’ section of the paper. Discuss the key assessment [story and physical exam] findings that resulted in the identification of the priority diagnosis/diagnoses indicated in the ‘A’ section of the paper As an advanced practice student you need to explore the evidence relative to the patient’s care needs and be able to document the rationale for the elements of the plan. Briefly provide rationales for the key elements of the plan of care [e.g. if a particular HTN medication is prescribed then reference the current JNC guidelines, if a particular antimicrobial is prescribed provide the source referenced for the decision, etc.] Provide a rationale for any care aspect included in the plan that is not consistent with the care approaches found in your course materials, EBP, CPGs or encompassed in the ‘community standard of care’. When using credible sources to support your discussion do not copy and paste from the sources. Paraphrase source information as you construct your discussion and ensure that you provide in-text and reference citations for the source. Identify any etcal or cultural issues related to ts patient’s care. Include how these concerns were addressed. Discuss the following: Choose at least one of the provisions of the Code and discuss how your experience with the patient encounter aligns with the tenants of the provision OR how you advocated for the patient during the encounter to ensure your actions aligned with the tenants of the provision. Link to gain access to the ANA Code of Etcs – you will need to scroll down to ‘Select One’ [option] to progress to the page where you will have full access to the Code: Links to articles that explore the issue of cultural concerns in health care: Construct a discussion that summarizes the barriers/potential barriers your patient faces relative to their ability to seek or receive healthcare services and exploration of at least 3 of the applicable ‘social determinants of health’ for your patient. Discuss the Following: Your discussion needs to include observations about access to care, financial barriers, and non-financial barriers beyond access. Be sure to provide in-text citations as appropriate for APA style guidelines in your discussion to support the literature that you reviewed in identifying the actual/potential barriers. Links to article exploring barriers Your discussion needs to include exploration of the three social determinants of health that you identified as having the most significant impact on your patient’s health care and health status. Be sure to provide in-text citations as appropriate for APA style guidelines in your discussion to support the literature that you reviewed in identifying the social determinants of health. Link to CDC’s information on Social Determinants of Health Include in your discussion at least one health care policy or initiative that you identified in the literature as having the potential to positively impact the identified actual/potential barriers or priority social determinants of health for your patient. Resources for your ‘search’ include the Herzing Library, Google Scholar, PubMed, and/or the Virginia Henderson Repository Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature wle differentiating between gh-quality and low-quality findings. Evidence-Based Practice includes the application of evidence and the evaluation of the outcomes to guide future practice. Ts section is a 1-2 paragraph summary of the scholarly evidence utilized to complete ts assignment. . Discuss the following: What clinical questions and terms did you use to direct your search in the library database? 2. . Identify all sources (APA citations) used that informed your decision making in ts particular case. 3. . Comment on the quality of the research or evidence based practice guidelines used. What is the level of evidence? How credible is it? Is it a just a recommendation or an expected standard of care? 4. How valuable was the evidence in understanding and directing the care in ts case? How did it influence your decision making? Were you able to assess the outcome? If so, are changes needed? * Ts is an area where you look over the data gathered and after a careful review of the available resources (i.e. text books, reference readings) will provide a reflection of what might have been added or deleted that would have made ts note more conclusive or complete. Ts is not an area to critique the preceptor. Discuss areas could you have changed? What areas might you have added, perhaps additional questions you should have asked in the ROS, or additional areas you may have assessed for in the PE? Identify the specific person that drove ts plan of care and developed the management, wle including detail in how you advocated for the patient. It is entirely possible, and desirable, that you drove the development of the plan of care.  Include how an individualized approach was applied to ts patient’s care. Also include how you identified your advocacy for the role of the Nurse Practitioner. Follow APA guidelines for constructing all reference page citations and ensure you used APA style for all in-text citations. 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