Soap Note (Due 6 hours)

  

1) ************Complete the template attached (See File 1) according to the example (See File 2 )   

               It is mandatory that you respect the information requested in the template

              You should not modify the template. The titles and subtitles will be verified

2)¨******APA norms  

            Dont write in the first person 

            Dont copy and pase the questions.

            Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

3) It will be verified by Turnitin and SafeAssign

4) Minimum 5 references not older than 5 years

_______________________________________________________________

Patient:

Name: AN

 Age:

36 years

Race:

White, Non Hispanic

Gender:

Female

Insurance:

Private insurance

Referral:

No referral 

 Chief Complaint

“Headache 

 ICD-10 Diagnosis Codes

G43.011 – MIGRAINE WITHOUT AURA, INTRACTABLE, WITH STATUS MIGRAINOSUS 

 CPT Billing Codes

99204 – OFFICE/OP VISIT, NEW PT, 3 KEY COMPONENTS:COMPREHENSIVE HX;COMPREHENSIVE EXAM;MED DECISN MOD COMPLEX 

Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic – NSAIDS
Neurology – Migraine
 

Informatics

 A hospital organization is looking to adopt an electronic health record (EHR). It is important that the technology meet the Centers for Medicare and Medicaid Services (CMS) Meaningful Use (MU) Criteria. Please explain as a DNP, how your role would be beneficial for the hospital in choosing a proper EHR to meet the needs of clinicians and the Meaningful Use criteria. Please examine all stages of the Meaning Use criteria and support your discussion with relevant scholarly research. 

Discussion: Pediatric Bipolar Depression Disorder Debate Week 8

  

Learning Resources

Required Readings

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

“Bipolar and Related Disorders”
“Depressive Disorders”

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Chapter 31, “Child Psychiatry” (pp. 1226–1253)

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.

Note: All Stahl resources can be accessed through the Walden Library using the link. This link will take you to a login page for the Walden Library. Once you log in to the library, the Stahl website will appear.

To access information on the following medications, click on The Prescriber’s Guide, 5th Ed. tab on the Stahl Online website and select the appropriate medication.

Zeanah, C. H., Chesher, T., & Boris, N. W. (2016). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder and disinhibited social engagement disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 55(11), 990–103. Retrieved from http://www.jaacap.com/article/S0890-8567(16)31183-2/pdf

 

Some debate in the literature exists specific to whether or not bipolar disorder can be diagnosed in childhood. While some have anecdotally argued that it is not possible for children to develop bipolar disorder (as normal features of childhood confound the diagnosis), other sources argue that pediatric bipolar disorder is a fact.

In this Discussion, you engage in a debate as to whether pediatric bipolar disorder is possible to diagnose.

Learning Objectives

Students will:
  • Evaluate diagnosis of pediatric bipolar depression disorder
  • Analyze consequences to diagnosing/failing to diagnose pediatric bipolar depression disorder

To Prepare for the Discussion:

  • The instructor will assign you a position for or against the issue of diagnosing pediatric bipolar depression disorder.
  • Review the Learning Resources concerning the controversy over the diagnosis of pediatric bipolar depression disorder.

 

Post:

  • Write “for” in the subject line of your Discussion post.

  • Based on the position you were assigned (FOR), justify whether or not pediatric bipolar depression disorder should be diagnosed.

Support your position with evidence and examples.

Note: In APA Format and proper citation, Support your rationale with a minimum of three academic resources/references no more than five years old. Include introduction and conclusion. 

 

Based on the requested outline, you should first ALWAYS provide some type of introduction based on the presenting issue using research.  Ex: According to the American Psychiatric Association (2015), depression has increased by……

Introduction….tell briefly about depression

History of Present Illness/Clinical Impression…..you should always have a mental status exam of the client you are seeing…..at every visit!!!!!!

Psychopharmacologic treatment….What does the research say about treating a client with depression.  Ex:  Harris 2018, stated the Serotonin Intake inhibitors are the first line treatment for depression due to the targeted neurotransmitters.   Although SSRI’s are considered first line treatment for depression, Mr. J was started on Wellbutrin 150mg instead because the preceptor felt that the Wellbutrin would assist Mr J with smoking cessation as well. Harris (2015) stated that Wellbutrin helps to decrease smoking by 50% due to….

Psychotherapy….Research states that Cognitive Behavioral Therapy is the best therapeutic approach with treating patients with Major Depression (Smith, 2019).  Cognitive Behav Therapy was discussed with Mr. j and the client is willing to participate in this therapy.

Medical Management…Mr J does not have any medical needs that need to be addressed at this time.  However, it is recommended that the client get baseline labs to ensure that there are no medical needs that may be the cause of the depression (Harris, 2016)

Students you should BOLD the headings!!!! The instructor should be able to immediately identify the pertinent information.

Now the RUBRIC…the guide to for a grade!!!  The rubric is graded as EXCELLENT, GOOD, FAIR, AND POOR.  You choose where you want to be

  1.  Analytical thinking…..comes from research,  This should be covered with the introduction
  2. Purpose Statement….The purpose of this assignment is to discuss a client with depression, treatment options, and appropriate interventions to properly care for Mr. J (This is simple) Can be included at the end of the introduction.
  3. Key concepts….did you address what the assignment ask you to do
  4. Are you using the required resources to back up the data
  5. Is the paper flowing
  6. Grammar…..GRADUATE STUDENTS…ESPECIALLY THOSE OF YOU WANTING TO OBTAIN A DOCTORATE try to avoid USING HE, SHE, THEY, US, I.  You can use the client, the daughter of the patient stated, the team, as a provider; etc.  The pronouns take away from the professional/scholarly writing within the paper….In my opinion.  See the examples above. However, it’s not against APA standards at this time…it’s now a preference for the avoidance of the pronoun use. 

Reflection on Learning ,

  

Week 3: Reflection on Learning

Reflective inquiry allows for expansion in self-awareness, identification of knowledge gaps, and assessment of learning goals. Each week, you will reflect upon what you have learned and complete a reflective journal assignment: Reflection on Learning. Each weekly reflection is placed in one document, which will be submitted for grading at the end of Week 7. There is no weekly reflection in Week 8 because a reflection is incorporated into the discussion question. Please review the Reflection Guidelines and Rubric (Links to an external site.) for complete assignment requirements. Create a document where you will keep your weekly reflection.

Access your reflection document. Reflect upon your Week 3 learning journey in NR701 and consider the following in one or two paragraphs.

· Provide one specific example of how you achieved the weekly objectives.

· What is the benefit of the learning?

· What values can you reaffirm or want to reconsider after this learning? 

Week 3: Readings

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Education-Resources/AACN-Essentials (Links to an external site.)

Resnik, D. B. (2015, May). National Institute of Environmental Health Sciences: Glossary of commonly used terms in research ethics. https://www.niehs.nih.gov/research/resources/bioethics/glossary/index.cfm (Links to an external site.)

Resnik, D. B. (2020, August 25). National Institute of Environmental Health Sciences: Research ethics timeline (1932-Present). https://www.niehs.nih.gov/research/resources/bioethics/timeline/index.cfm (Links to an external site.)

 

Week 4: Reflection on Learning

Reflective inquiry allows for expansion in self-awareness, identification of knowledge gaps, and assessment of learning goals. Each week, you will reflect upon what you have learned and complete a reflective journal assignment: Reflection on Learning. Each weekly reflection is placed in one document, which will be submitted for grading at the end of Week 7. There is no weekly reflection in Week 8 because a reflection is incorporated into the discussion question. Please review the Reflection Guidelines and Rubric (Links to an external site.) for complete assignment requirements. Create a document where you will keep your weekly reflection.

Access your reflection document. Edit this page to include your reflection for Week 4. Reflect upon your Week 4 learning journey in NR701 and consider the following in one or two paragraphs.

· Provide one specific example of how you achieved the weekly objectives.

· Which change model or conceptual framework did you find most valuable and why?

· In what ways, if any, do your practices inhibit reform? 

Week 4: Readings

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Education-Resources/AACN-Essentials (Links to an external site.)

 

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (2016). Translation of evidence into nursing and health care (2nd ed.). Springer Publishing Company.

· Chapter 3: Change Theory and Models: Framework for Translation

Week 5: Reflection on Learning

Reflective inquiry allows for expansion in self-awareness, identification of knowledge gaps, and assessment of learning goals. Each week, you will reflect upon what you have learned and complete a reflective journal assignment: Reflection on Learning. Each weekly reflection is placed in one document, which will be submitted for grading at the end of Week 7. There is no weekly reflection in Week 8 because a reflection is incorporated into the discussion question. Please review the Reflection Guidelines and Rubric (Links to an external site.) for complete assignment requirements. Create a document where you will keep your weekly reflection.

Access your reflection document. Edit this page to include your reflection for Week 5. Reflect upon your Week 5 learning journey in NR701 and consider the following in one or two paragraphs.

· Provide one specific example of how you achieved the weekly objectives.

· Which translation model did you find most valuable and why?

· How receptive are you to embracing change and reform? 

Week 5: Readings

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Education-Resources/AACN-Essentials  (Links to an external site.)

 

Harvey, G., & Kitson, A. (2016). PARiHS revisited: From heuristic to integrated framework for the successful implementation of knowledge into practice (Links to an external site.). Implementation Science, 10, 33. https://doi.org/10.1186/s13012-016-0398-2  (Links to an external site.)

May, C. (2006). A rational model for assessing and evaluating complex interventions in health care (Links to an external site.). BMC Health Services Research, 6, 86-11. https://doi.org./10.1186/1472-6963-6-86  (Links to an external site.)

May, C., Finch, T., Mair, F., Ballini, L., Dowrick, C., Eccles, M., Heaven, B. (2007). Understanding the implementation of complex intervention in health care: The normalization process model (Links to an external site.). BMC Health Services Resarch, 7, 148. https://doi.org/10.1186/1472-6963-7-148

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (2016). Translation of evidence into nursing and health care (2nd ed.). Springer Publishing Company.

· Chapter 2: The Science of Translation and Major Frameworks

Week 6: Reflection on Learning

Reflective inquiry allows for expansion in self-awareness, identification of knowledge gaps, and assessment of learning goals. Each week, you will reflect upon what you have learned and complete a reflective journal assignment: Reflection on Learning. Each weekly reflection is placed in one document, which will be submitted for grading at the end of Week 7. There is no weekly reflection in Week 8 because a reflection is incorporated into the discussion question. Please review the Reflection Guidelines and Rubric (Links to an external site.) for complete assignment requirements. Create a document where you will keep your weekly reflection.

Access your reflection document. Edit this page to include your reflection for Week 6. Reflect upon your Week 6 learning journey in NR701 and address the following in one or two paragraphs.

· Provide one specific example of how you achieved the weekly objectives.

· What approach do you use in working with others throughout the change process?

· What is your response to change? Is it inclusive of other team members? Why or why not? 

Week 6: Readings

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Education-Resources/AACN-Essentials (Links to an external site.)

 

Dang, D., & Dearholt, S. L. (2018). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd ed.). Sigma Theta Tau International.

· Chapter 9: Creating a Supportive EBP Environment

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (2016). Translation of evidence into nursing and health care (2nd ed.). Springer Publishing Company.

· Chapter 13: Interprofessional Collaboration and Practice for Translation

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Week 7: Reflection on Learning

Reflective inquiry allows for expansion in self-awareness, identification of knowledge gaps, and assessment of learning goals. Each week, you will reflect upon what you have learned and complete a reflective journal assignment: Reflection on Learning. Each weekly reflection is placed in one document, which will be submitted for grading at the end of Week 7. There is no weekly reflection in Week 8 because a reflection is incorporated into the discussion question. Please review the Reflection Guidelines and Rubric (Links to an external site.) for complete assignment requirements. Create a document where you will keep your weekly reflection.

Access your reflection document. Edit this page to include your reflection for Week 7. Reflect upon your Week 7 learning journey in NR701 and address the following in one or two paragraphs.

· Provide one specific example of how you achieved the weekly objectives.

· What goals will you set in accordance with what you have learned?

· How has course information changed your ways of knowing? 

Week 7: Readings

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Education-Resources/AACN-Essentials (Links to an external site.)

 

Dang, D., & Dearholt, S. L. (2018). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd ed.). Sigma Theta Tau International.

· Chapter 9: Creating a Supportive EBP Environment

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (2016). Translation of evidence into nursing and health care (2nd ed.). Springer Publishing Company.

· Chapter 15: Best Practices in Translation: Challenges and Barriers in Translation

Medication error

 

Medication error reporting is an essential component of patient safety. Please review the following article:

Alsulami, S. L., Sardidi, H., Almuzaini, R. S., Alsaif, M. A., Almuzaini, H. S, & Moukaddem A. K. (2019). Knowledge, attitude and practice on medication error reporting among health practitioners in a tertiary care setting in Saudi ArabiaSaudi Medical Journal, 40(3), 246-251.

Write a 5-6-page paper, not including the cover and reference pages, using the readings, research, and your knowledge of medication error reporting to analyze the following:

  • The prevalence and common causes of medication errors
  • Consequences on patients including types of harm
  • The barriers to medication error reporting
  • Provide a recommendation for policies and procedures addressing the reporting of medical errors
  • Recommend how to evaluate whether the policy is effective

Your report should meet the following structural requirements:

  • Be 5-6 pages in length, not including the cover or reference pages.
  • Be formatted according to Saudi Electronic University and APA writing guidelines.
  • Provide support for your statements with in-text citations from a minimum of six scholarly articles. Two of these sources may be from the class readings, textbook, or lectures, but four must be external.
  • Utilize headings to organize the content of your work.

You are strongly encouraged to submit all assignments to the Turnitin Originality Check prior to submitting them to your instructor for grading. If you are unsure how to submit an assignment to the Originality Check tool, review the Turnitin Originality Check Student Guide.

Shadow Health: Focused Exam: Cough Results

 

Within the Shadow Health platform, complete the Focused Exam: Cough Results. The estimated average time to complete this assignment each time is 1 hour and 15 minutes. Please note, this is an average time. Some students may need longer. 

This clinical experience is a focused exam. Students must score at the level of “Proficiency” in the Shadow Health Digital Clinical Experience. Students have three opportunities to complete this assignment and score at the Proficiency level. Upon completion, submit the lab pass through the assignment dropbox.

Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 100 points; students successfully scoring at the Proficiency level on the second attempt will earn a grade of 90 points; and students successfully scoring at the Proficiency level on the third attempt will earn a grade of 80 points. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (68 points).

Case analysis

Your case study this week will focus on the following scenario:
Patient is a 24-year-old female administrative assistant who comes to the emergency department with a chief complaint of severe right-sided headache. She states that this is the sixth time in the last 2 months she has had this headache. She says the headaches last 2–3 days and have impacted her ability to concentrate at work. She complains of nausea and has vomited three times in the last 3 hours. She states, “the light hurts my eyes.” She rates her pain as a 10/10 at this time. Ibuprofen and acetaminophen ease her symptoms somewhat but do not totally relieve them. No other current complaints.
Assignment (1- to 2-page case study analysis)
In your Case Study Analysis related to the scenario provided, explain the following:
Both the neurological and musculoskeletal pathophysiologic processes that would account for the patient presenting these symptoms.
Any racial/ethnic variables that may impact physiological functioning.
How these processes interact to affect the patient.