Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.
- Select a patient encounter from your current clinical experience.
- The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
NOTE: You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.
- For this assignment you will utilize the same SOAP note format that you do for your Typhon encounters and expand your documentation. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page (Page 1): Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective (Start of Page 2): Follow APA guidelines for running head on page 2 and subsequent pages
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
Medications: Names, dosages, and routes of administration.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
ROS: review of systems – this is to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history 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. While 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 chief complaint.
General: May include if patient has had a fever, chills, 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:
*Objective:
PE: physical exam – either limited for a focused exam or more extensive for a complete history and physical assessment. This 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. While 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 chief 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.
Gen: general statement of appearance, if there is any acute distress.
VS: vital signs, height and weight, BMI
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
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc).
*Assessment: (number each diagnosis)
Diagnosis/Diagnoses: Start with the presenting chief 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 this diagnosis. Pertinent positives and negatives must be found in the write-up.
*Plan: (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):
Diagnostics: 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 chief complaint.
Therapeutic: changes in meds, skin care, counseling
Educational: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.
*Clinical Decision Making
The next section summarizes your critical thinking, 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 label each area as appropriate. All information should be in your own words. Do not cut and paste information obtained as this is considered academically dishonest.
Pathophysiology (1 paragraph): Include information in regard to the pathophysiology related to the main diagnosis or illness process. This will help to understand how the S and O supported the diagnosis you assigned.
Pharmacology information (1 paragraph) or (***Alternate – Therapy information): Choose one drug that was prescribed at this 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 this particular drug is being prescribed for this particular patient, what is this 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. This should be about a paragraph in length stated in the way that you would use to educate your patient regarding the medication. It is not acceptable to copy and paste from your pharmacology resource or text. Please cite resources used. ***NOTE: Since the patient encounter you select for this assignment is supposed to be one of the most complex encounters you have with this course population, the likelihood exists that you will have a pharmacologic agent to discuss for this assignment requirement. However, if there are no pharmacologic agents to utilize then choose a non-pharmacologic element of the therapeutic plan (e.g. this 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.]
Critical Thinking / Clinical Decision Making (1 paragraph): In this section, include the top 2-3 differential diagnoses. This is an area that you would want to discuss what led to the diagnosis and how you ruled out certain other differential diagnosis. You may want to include why a particular treatment was chosen, perhaps despite what the books and references say. You need to provide evidence that you are referring to your available resources and not just deferring to your preceptor. Address any personal biases related to aging, development, and independence that might interfere with delivering quality of care.
Ethical and or Cultural Concerns: Identify any ethical or cultural issues related to this patient’s care. Include how these concerns were addressed.
Barriers to Care: Identify any potential or actual barriers you encountered or foresee with this patient’s care. Specifically here address the social determinants of health that impact/result in actual or potential barriers to their ability to receive/engage with healthcare services. Your discussion need to demonstrate knowledge of healthcare policy and advocacy actions/activities appropriate for quality healthcare for all citizens. As an advanced practitioner it is important to keep up to date with health care policy in order to provide quality patient care. This information may be obtained in journals, blogs, media, etc.
*Evidence based practice (1-2 paragraphs):
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 while differentiating between high-quality and low-quality findings. The practice of Evidence-Based Practice includes five fundamental steps:
- Formulating a well-built question
- Identifying articles and other evidence-based resources that answer the question
- Critically appraising the evidence [research studies, CPGs, published care standards, etc.] to assess its validity
- Applying the evidence
- Re-evaluating the application of evidence and areas for improvement
In this section please include APA citation for all resources utilized that informed your decision making with this particular patient case. In addition, describe what clinical questions and terms used to direct your search and address how valuable the evidence you found was in understanding, and directing the care.
*Self-Reflection:
Reflection on decision making (1 paragraph): This 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 this note more conclusive or complete. This is not an area to critique the preceptor. What 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?
Advanced Practice Practitioner Role Analysis (1 paragraph): Identify the specific person that drove this plan of care and developed the management, while 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 this patient’s care. Also include how you identified your advocacy for the role of the Nurse Practitioner.
*Reference Page: Follow APA guidelines for constructing all reference page citations and ensure you used APA style for all in-text citations.
