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Problem-Focused SOAP Note Format

Demographic Data 

• Age and gender (must be HIPAA compliant) 

Subjective 

• Chief Complaint (CC): A short statement about why they are there 
• History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment 
• Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance 
• Family Hx: any history of CA, DM, HTN, MI, CVA?  
• Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc. 
• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy) 

Objective 

• Vital Signs 
• Physical findings listed by body systems, not paragraph form- Highlight abnormal findings 

Assessment (the diagnosis) 

• At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each 
• Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation 

Plan 

• Dx Plan (lab, x-ray) 
• Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any) 
• Pt. Education, including specific medication teaching points 
• Referral/Follow-up 
• Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due 

Reference 

• Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly. 

homework

For each course, you will be required a reflective discussion on how the course outcomes, the program outcomes, and the DNP Essentials were achieved throughout the course. Please familiarize yourself with each essential. 

Select two essentials and explain how you will be incorporating them into your practicum project as a DNP student. In Addition, select three leadership role-specific competencies from the AONL packet and explain how you will be achieving those during the DNP journey.

Possible project theme:  Determine effectiveness of antineuropathic medication to enhace pain management outcomes in patients with neuropathicc pain over opioids as first-line treatment for lumbar radiculopathy 

The purpose of this assignment is to examine Clinical Decision Support Systems (CDSS) to determine their application in addressing health equity. Develop a presentation outlining task force goals and relevant information for implementing a CDSS system to improve equity of care and promote health for all patients.

This assignment has indirect care experience requirements. The “Indirect Care Experience Hours” form, found in the Topic 3 Resources, will be used to document the indirect care experience hours completed in Topics 3, 4 and 5. As progress is made on this and subsequent assignments, update this form indicating the date(s) each section is completed. This form will be submitted in Topic 5. In your role as a nurse informaticist, you have been asked by the Chief Informatics Officer (CIO) to evaluate several clinical decision-making tools to be used by your organization’s stakeholders. The selected Clinical Decision Support Systems (CDSS) will be used to analyze the current state of health equity and information literacy in your organization.

Your first step is to create a task force of stakeholders to participate in the CDSS selection process. Prepare a 10-12 slide PowerPoint presentation for the first task force meeting to include these agenda items:

• Reason for the Project: Explain the organizational need, reason for the project, rationale for implementing a clinical decision-making tool in your organization. Discuss how CDSS can improve health equity and information literacy in your organization.
• Task Force Selection: Explain why you have been selected to lead this project. In your speaker notes, explain the role of each stakeholder and why they were selected to serve on this task force.
• Research: Conduct research and identify one popular CDSS system used in the health care industry, include a description of the CDSS system.
• Basic Concepts of Systems: Review the information and communication technologies (in the electronic health record, mobile health, and telehealth systems). Select one communication technology and discuss how a clinical decision-making tool can be incorporated to improve health equity in patient care.
• Crucial Functionality: Describe the crucial functions of the selected CDSS. Explain why it is essential to the clinical workflow. Explain the impact of the CDSS on health information exchange, interoperability, and integration of health care.
• Task Force Communication: Describe how communication technologies support documentation of care and communication among providers and patients at all system levels. Discuss how communication technology will be used to communicate with the task force members during the project.

Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style.

The title slide and reference slide are not included in the slide count. Include speaker notes below each content-related slide that represent what would be said if giving the presentation in person. Expand upon the information included in the slide and do not simply restate it. Please ensure the speaker notes include a minimum of 50-75 words.

Cite a minimum of three sources to complete this assignment. Sources must be published within the last 5 years, appropriate for the assignment criteria, and relevant to nursing practice.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Explain the role of communication technology in enhancing clinical information flows. Name three contemporary communication technologies used in acute care facilities. How is Artificial Intelligence (AI) and machine learning changing the functionality of these platforms?

Initial discussion question posts should be a minimum of 200 words and include at least two references cited using APA format. Responses to peers or faculty should be 100-150 words and include one reference. Refer to “RN-BSN Discussion Question Rubric” and “RN-BSN Participation Rubric,” located in Class Resources, to understand the expectations for initial discussion question posts and participation posts, respectively. 

Part 2Literature Review 

Begin by describing which databases you searched, search terms you used related to your topic, how you narrowed your search, how you selected those references you will discuss in this section.

Summary of Article

This section should discuss at least 5 articles/peer reviews on the topic. The content of this section should be separated bolded headers between the summary of each article.