JCPatient ID: 119531646DOB: 1/4/1981Sex: FAccount No.: Encounter ID: 262700526Encounter Date: 07/29/2022 Encounter Type: Office Visit SUBJECTIVE: Chief Complaint: Established care. Physical and well-woman visit History Of Present Illness: The patient is a 41-year-old female who presented for physical and well-woman care. The patient is new in the area, she moves from Michigan state. She has a History of hysterectomy in 2012, Cervix removed Breast implant silicone. Has a mood disorder and is experiencing insomnia, multiple surgery, and digestive issues. The patient was very obese, for which she underwent bariatric surgery. The patient c/o BLE cramping and BUE pain. She needs a psychiatrist in the area. Will need a cardiologist to consult due to a family history of heart disease? Multiple chronic health issues are controlled with medications. Rates bilateral knee pain as 4/10. Medical History: Sphincter of Oddi dysfunction Pancreatitis liver problems Colonoscopy in 2015 Colonoscopy in 1017, repeated in 2020 Sleep apnea Insomnia Depression Panic attacks Mood disorder Surgical History: Pancreatic surgery in 2020 Bariatric surgery in 2018 Hysterectomy in 2012 Cervix removed Breast implant silicone Gynecological History: Hysterectomy in 2012, Cervix removed, Breast implant silicone Family History: Her great grandfather; had colon cancer Father; heart failure Mother; hyperlipidemia and thyroid disease Sibling; Healthy, no health issues Social History: She drinks I cup of coffee a day a history of 20 years pack smoker-she quit smoking one month ago and started Chantix 1 month ago. The patient denies alcohol intake and the use of illicit drugs. She has used glasses since 2022 and sees an eye doctor. Will need a dentist referral for wisdom teeth removal. She eats 3-5 meals on the go. She sees a psychiatrist in Azle, texas. Smoking Status: Former Smoker Allergies: Trazodone Tramadol Cipro Current Medications: Venlafaxine 150mg ER bid alprazolam 0.25mg daily as needed Hyoscyamine 0.125mg 1 po QID Ondansetron 4mg 1 po as needed Review of System: Constitutional: Denies weight loss, fever, chills, weakness, or fatigue. Head: Denies headache, lightheadedness, or vertigo Neck: Denies pain, stiffness, or tenderness. Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears: Denies hearing loss, tinnitus, pain, vertigo, or use of an assistive hearing device. Nose: Denies sneezing, congestion, runny nose, discharge, obstruction, epistaxis, or sinus issues Mouth: Admit she needs to see the dentist for wisdom teeth removal Throat: Denies sore throat, hoarseness, and dysphagia. Cardiovascular: Denies chest pain, chest pressure, chest discomfort, palpitations, edema, or claudication Respiratory: Denies cough, sputum, SOB, chest congestion, Wheezing, Phlegm, or hemoptysis Gastrointestinal: Admit history Sphincter of Oddi dysfunction, pancreatitis, and liver problems Genitourinary: Denies nocturia, dysuria, incontinence, frequency, urgency, or blood in the urine Musculoskeletal: Admit bilateral knee pain Integumentary(Skin and/or Breast): Denies rash, itching, abnormal lesions or skin problems Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Psychiatric: Admit depression and panic attacks. The patient sees a psychiatrist pcp Endocrine: Admit pancreatitis. Denies Excessive appetite, Excessive thirst, Heat intolerance, Cold intolerance Hematologic/Lymphatic: Denies anemia, bleeding, or bruising. No enlarged nodes. No history of splenectomy Allergic/Immunologic: Denies history of asthma, hives, eczema, itching, nasal congestion, rash, rhinitis, environment OBJECTIVE: Vital Signs: Height: 64.00 in Weight: 183.00 lbs BMI: 31.41 Blood Pressure: 114/80 mmHg Temperature: 97.90 F Pulse: 81 beats/min Resp. Rate: 16 Physical Exam: Constitutional: A 41-year-old well-developed, well-nourished, female who is alert, oriented, and cooperative. She is a good historian and answers questions readily and appropriately. She appears to be in no acute distress. Ears, Nose, Mouth, and Throat: Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal, Started using since 2022, ear: EAC’s clear, TM’s normal, Throat: clear, no exudates, Neck: supple, adenopathy, no thyromegaly, no carotid bruits Cardiovascular: Cardiologist consult; family history of heart disease Chest/Breasts: History silicone breast implant Heart: RRR, no murmur, no gallops, or rubs Gastrointestinal (Abdomen): History of Pancreatitis, Genitourinary: no Burning/painful urination, Frequency, Urgency, Night time urination, Blood in the Urine Musculoskeletal: The pat is present with bilateral knee pain Skin: Warm and dry, rashes or abnormal lesions, Extremities: Full ROM without deformities; no clubbing, edema, or cyanosis Neurological/Psychiatric: The patient presented with depression and panic attacks. She sees a psychiatrist ASSESSMENT: Assessments: ICD-10 Assessments: Multiple chronic health issues PLAN: Care Plan: New patient labs work order today. Advise on Mammogram to be done Advise on a healthy diet and exercise to reduce the risk of cardiovascular disease Weight loss to prevent obesity Start gabapentin 600mg po at bedtime Vitamin B12 5000mg Refill needed medications today Cardiologist referral Psychiatrist referral Patient Instructions: Take medication as prescribed ___________________________ Date: _________ [Provider]: Jackie Thomas, APRN Assignment 2: Comprehensive Well-Woman ExamFor a wide variety of medical conditions, early detection of the problem enables timely and more effective treatment. Annual well-woman exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women. Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.Photo Credit: Teodor Lazarev / Adobe StockFor this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.To prepare:Reflect on your practicum experience and select a female patient whom you have examined with the support and guidance of your Preceptor.Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, and treatment and management plan, and education strategies and follow-up care.What additional considerations might you think about if your patient was pregnant or just delivered?Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.Assignment:Write an 8- to 10-page Comprehensive Well-Woman Exam that addresses the following:Age, race and ethnicity, and partner status of the patientCurrent health status, including chief concern or complaint of the patientContraception method (if any)Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)Review of systemsPhysical examLabs, tests, and other diagnosticsDifferential diagnosesManagement plan, including diagnosis, treatment, patient education, and follow-up careProvide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.ReflectionReflect on some additional factors for your patient:What are the implications if your patient was pregnant or just delivered?What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm).Note: Your Comprehensive Well-Woman Exam Assignment must be signed by Day 7 of Week 10.Jodi clarmontPatient ID:119531646DOB:1/4/1981Sex:FAccount No.: Encounter ID:262700526Encounter Date:07/29/2022 Encounter Type: Office Visit SUBJECTIVE: Chief Complaint: Established care. Physical and well-woman visit History Of Present Illness: The patient is a 41-year-old female who presented for physical and well-woman care. The patient is new in the area, she moves from Michigan state. She has a mood disorder, and is experiencing insomnia, multiple surgery, and digestive issues. The patient was very obese, for which she underwent bariatric surgery. The patient c/o BLE cramping and BUE pain. She needs a psychiatrist in the area. Will need a cardiologist to consult due to a family history of heart disease? Multiple chronic health issues are controlled with medications. Rates bilateral knee pain as 4/10. Medical History: Sphincter of Oddi dysfunction Pancreatitis liver problems Colonoscopy in 2015 Colonoscopy in 1017, repeated in 2020 Sleep apnea Insomnia Depression Panic attacks Mood disorder Surgical History: Pancreatic surgery in 2020 Bariatric surgery in 2018 Hysterectomy in 2012 Cervix removed Breast implant silicone Gynecological History: Hysterectomy in 2012, Cervix removed, Breast implant silicone Family History: Her great grandfather; had colon cancer Father; heart failure Mother; hyperlipidemia and thyroid disease Sibling; Healthy, no health issues Social History: She drinks I cup of coffee a day a history of 20 years pack smoker-she quit smoking one month ago and started Chantix 1 month ago. The patient denies alcohol intake and the use of illicit drugs. She has used glasses since 2022 and sees an eye doctor. Will need a dentist referral for wisdom teeth removal. She eats 3-5 meals on the go. She sees a psychiatrist in Azle, texas. Smoking Status: Former Smoker Allergies: Trazodone Tramadol Cipro Current Medications: Venlafaxine 150mg ER bid alprazolam 0.25mg daily as needed Hyoscyamine 0.125mg 1 po QID Ondansetron 4mg 1 po as needed Review of System: Constitutional: Denies weight loss, fever, chills, weakness, or fatigue. Head: Denies headache, lightheadedness, or vertigo Neck: Denies pain, stiffness, or tenderness. Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears: Denies hearing loss, tinnitus, pain, vertigo, or use of an assistive hearing device. Nose: Denies sneezing, congestion, runny nose, discharge, obstruction, epistaxis, or sinus issues Mouth: Admit she needs to see the dentist for wisdom teeth removal Throat: Denies sore throat, hoarseness, and dysphagia. Cardiovascular: Denies chest pain, chest pressure, chest discomfort, palpitations, edema, or claudication Respiratory: Denies cough, sputum, SOB, chest congestion, Wheezing, Phlegm, or hemoptysis Gastrointestinal: Admit history Sphincter of Oddi dysfunction, pancreatitis, and liver problems Genitourinary: Denies nocturia, dysuria, incontinence, frequency, urgency, or blood in the urine Musculoskeletal: Admit bilateral knee pain Integumentary(Skin and/or Breast): Denies rash, itching, abnormal lesions or skin problems Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Psychiatric: Admit depression and panic attacks. The patient sees a psychiatrist pcp Endocrine: Admit pancreatitis. Denies Excessive appetite, Excessive thirst, Heat intolerance, Cold intolerance Hematologic/Lymphatic: Denies anemia, bleeding, or bruising. No enlarged nodes. No history of splenectomy Allergic/Immunologic: Denies history of asthma, hives, eczema, itching, nasal congestion, rash, rhinitis, environment OBJECTIVE: Vital Signs: Height: 64.00 in Weight: 183.00 lbs BMI: 31.41 Blood Pressure: 114/80 mmHg Temperature: 97.90 F Pulse: 81 beats/min Resp. Rate: 16 Physical Exam: Constitutional: A 41-year-old well-developed, well-nourished, female who is alert, oriented, and cooperative. She is a good historian and answers questions readily and appropriately. She appears to be in no acute distress. Ears, Nose, Mouth, and Throat: Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal, Started using since 2022, ear: EAC’s clear, TM’s normal, Throat: clear, no exudates, Neck: supple, adenopathy, no thyromegaly, no carotid bruits Cardiovascular: Cardiologist consult; family history of heart disease Chest/Breasts: History silicone breast implant Heart: RRR, no murmur, no gallops, or rubs Gastrointestinal (Abdomen): History of Pancreatitis, Genitourinary: no Burning/painful urination, Frequency, Urgency, Night time urination, Blood in the Urine Musculoskeletal: The pat is present with bilateral knee pain Skin: Warm and dry, rashes or abnormal lesions, Extremities: Full ROM without deformities; no clubbing, edema, or cyanosis Neurological/Psychiatric: The patient presented with depression and panic attacks. She sees a psychiatrist ASSESSMENT: Assessments: ICD-10 Assessments: Multiple chronic health issues PLAN: Care Plan: New patient labs work order today. Advise on Mammogram to be done Advise on a healthy diet and exercise to reduce the risk of cardiovascular disease Weight loss to prevent obesity Start gabapentin 600mg po at bedtime Vitamin B12 5000mg Refill needed medications today Cardiologist referral Psychiatrist referral Patient Instructions: Take medication as prescribed ___________________________ Date: _________ [Provider]: Jackie Thomas, APRNLearning ResourcesRequired Readings (click to expand/reduce)Fowler, G. C. (2019). Pfenninger and Fowler’s Procedures for Primary Care (4th ed.). Elsevier.
Section 10, “Obstetrics”Chapter 162, “Dilation and Curettage” (pp. 1093–1099)Fanslow, J., Wise, M. R., & Marriott, J. (2019). Intimate partner violence and women’s reproductive health. Obstetrics, Gynaecology & Reproductive Medicine, 29(12), 342–350.
Rubric Detail
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Name: PRAC_6552_Week10_Assignment3_Rubric
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Write an 8- to 10-page Comprehensive Well-Woman Exam that addresses the
following:
• Age, race and ethnicity, and partner status of the patient
• Current health status, including chief concern or complaint of the patient
• Contraception method (if any)
• Patient history, including medical history, family medical history, gynecologic
history, obstetric history, and personal social history (as appropriate to current
problem)
• Review of systems
• Physical exam
• Labs, tests, and other diagnostics
• Differential diagnoses
• Management plan, including diagnosis, treatment, patient education, and followup care
• Provide evidence-based guidelines to support treatment plan.-Excellent
40.5 (40.5%) – 45 (45%)
Good
36 (36%) – 40 (40%)
Fair
31.5 (31.5%) – 35 (35%)
Poor
0 (0%) – 34 (34%)
Reflect on the following:
Reflect on some additional factors for your patient:
• What are the implications if your patient was pregnant or just delivered?
• What are implications if you have observed or know of some domestic violence?
Would this change your plan of care? If so, how?-Excellent
36 (36%) – 40 (40%)
Good
32 (32%) – 39 (39%)
Fair
28 (28%) – 31 (31%)
Poor
0 (0%) – 30 (30%)
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.-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-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,
parenthetical/in-text citations, and reference list.-Excellent
5 (5%) – 5 (5%)
Good
4 (4%) – 4 (4%)
Fair
3.5 (3.5%) – 3.5 (3.5%)
Poor
0 (0%) – 3 (3%)
Total Points: 100
Name: PRAC_6552_Week10_Assignment3_Rubric
PRAC 6552: Advanced Nurse Practice in Reproductive Health Care Practicum
Guidelines for a Comprehensive History and Physical SOAP
Note
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Label each section of the SOAP note (each body part and system).
Do not use unnecessary words or complete sentences.
Use standard abbreviations.
SUBJECTIVE DATA (S): (information the patient/caregiver tells you)
Includes all of the information the patient tells you. Identifying data: Initials, age, race,
gender, marital status. Name of informant, if not patient.
CHIEF COMPLAINT (CC): The reason for this health care visit. A statement describing
the symptom(s), problem, condition, diagnosis, physician-recommended return, or other
factors that are the reason for this patient visit (even if they bring no specific problem). If
possible, use the patient’s own words in quotation marks.
HISTORY OF PRESENT ILLNESS (HPI): If the patient presents with specific problems,
symptoms, or complaints, a chronological description of the development of the
patient’s present illness from the first sign of each symptom to the current visit is
recorded using the elements of a symptom analysis. Those elements are:
• Location: Where it started, where it is located now
• Quality: Unique properties or characteristics of the symptom
• Severity: Intensity, quantity, or impact on life activities; duration: length of
episode
• Timing: When symptom started, frequency (patient’s “story” of the symptom),
context (under what conditions it occurs)
• Setting: Under what conditions the symptoms occur, activities that produce the
symptoms
• Alleviating and aggravating factors: What makes it better and/or worse, what
meds have been taken to relieve symptoms, did the meds help or not, does food
make symptoms worse or better
• Associated signs and symptoms: Presence or absence of other symptoms or
problems occurring with their complaint; include pertinent negatives and
information from the patient’s charts (e.g., lab data or previous visit information)
In the case of a well visit, describe the patient’s usual health and summarize health
maintenance needs and activities.
PAST MEDICAL HISTORY (PMH):
? Allergies
? Current medications: prescription and over the counter
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PRAC 6552: Advanced Nurse Practice in Reproductive Health Care Practicum
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Age/health status
Appropriate immunization status
Previous screening tests result
Dates of illnesses during childhood (may not be very important in adults;
exceptions may include rheumatic fever or chronic illnesses continuing into
adulthood)
Major adult illnesses (include history of diabetes, hypertension, gastrointestinal
diseases, pulmonary disease, cardiovascular disease, cancer, tuberculosis,
sexually transmitted infections (STIs), HIV/AIDS, gynecological or urological
problems, drug and/or alcohol abuse, and psychiatric illness)
Injuries
Hospitalizations (reason, hospital, attending physician [if known])
Surgeries (include hospital and year)
FAMILY HISTORY (FH): Age and current health status or age at death and cause of
death of each family member (parents, siblings, and children) is recorded. Occurrence
within the family of illnesses of an environmental, genetic, or familial nature are
recorded in family history. Ask about the presence in the family of any of the following
conditions: asthma, glaucoma, myocardial infarctions, heart failure, hypertension,
cancer, tuberculosis, diabetes, kidney disease, hemophilia, sickle cell trait or disease,
psychiatric diseases, alcoholism allergies, family violence, mental retardation, epilepsy,
and congenital abnormalities.
Record any specific diseases related to problems identified in CC, HPI, or review of
symptoms (ROS).
SOCIAL HISTORY (SH): Record important life events: marital status, occupational
history, military service, level of education. Record lifestyle and current health habits
(may be here or in ROS): exercise, diet, safety (smoke alarms, seatbelts, firearms,
sports), living arrangements, hobbies, travel. Record religious preference relevant to
health, illness, or treatment. Record habits: use of drugs, alcohol, and tobacco.
Resources: resources to pay for care, insurance, worries about cost of care, history of
postponing care.
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant
(gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used),
types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any
sexual concerns.
REVIEW OF SYSTEMS (ROS): There are 14 systems for review. Record a summary
for each system. Unexpected or positive findings need complete symptom
analysis.
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PRAC 6552: Advanced Nurse Practice in Reproductive Health Care Practicum
1) Constitutional symptoms: Overall health, weight gain or loss, ideal weight,
fever, fatigue, repeated infections, ability to carry out activities of daily living.
2) Eyes: eye care, poor eyesight, double or blurred vision, use of corrective lenses
or medications, redness, excessive tearing, pain, trauma, date and results of last
vision screening or eye exam
3) Ears, nose, mouth, and throat: Ears: hearing acuity, exposure to high noise
level, tinnitus, and presence of infection or pain, vertigo, use of assistive hearing
device. Nose: sense of smell, discharge, obstruction, epistaxis, sinus trouble.
Mouth and teeth: use of oral tobacco or smoking cigarettes, last dental exam
date and result, pattern of brushing and use of dental floss and fluoride
toothpaste, dentures, bleeding of gums, sense of taste, mouth odor or ulcers,
sore tongue. Throat: sore throat, hoarseness, dysphagia.
4) Cardiovascular: Exercise pattern to maintain cardiovascular health. History of
abnormal heart sounds (including murmur), chest pains, palpitations, dyspnea,
activity intolerance, usual blood pressure, ECG (date, reason), cholesterol level
(date), edema, claudication, varicose veins.
5) Respiratory: Exposure to passive smoke. History of respiratory infections, usual
self-treatment, cough, last chest x-ray (date, result), exposure to tuberculosis
(TB) and last TB skin test (date and result), difficult breathing, wheezing,
hemoptysis, sputum production (character, amount), night sweats.
6) Gastrointestinal: Dietary pattern, fiber and fat in diet, use of nutritional
supplements (vitamins, herbs), heartburn, epigastric pain, abdominal pain,
nausea and vomiting, food intolerance, flatulence, diarrhea, constipation, usual
bowel pattern, change in stools, hemorrhoids, jaundice.
7) Genitourinary: Nocturia, dysuria, incontinence, sexual practices, sexual
difficulty, venereal disease, history of stones. Men: slow stream, penile
discharge, contraceptive use, self-testicular exam. Women: onset, regularity,
dysmenorrhea, intermenstrual discharge or bleeding, pregnancy history (number,
miscarriages, abortions, duration of pregnancy, type of delivery, complications),
menopause (if present, use of hormone replacement therapy), last menstrual
period (LMP), contraceptive use, last pap smear (date and result), intake of folic
acid.
8) Musculoskeletal: Exercise pattern, use of seatbelts, use of safety equipment
with sports, neck pain or stiffness, joint pain or swelling, incapacitating back pain,
paralysis, deformities, changes in range of motion of activity, screening for
osteoporosis, knowledge of back injury/pain prevention.
9) Integumentary (skin and/or breast): Use of skin protection with sun exposure,
self-examination practices in assessing skin, general skin condition and care,
changes in skin, rash, itching, nail deformity, hair loss, moles, open areas,
bruising. Breast: practice of self-breast exam, lumps, pain, discharge, dimpling,
last mammogram (date and result).
10) Neurologic: Muscle weakness, syncope, stroke, seizures, paresthesia,
involuntary movements or tremors, loss of memory, severe headaches.
11) Psychiatric: Nightmares, mood changes, depression, anxiety, nervousness,
insomnia, suicidal thoughts, potential for exposure to violence.
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PRAC 6552: Advanced Nurse Practice in Reproductive Health Care Practicum
12) Endocrine: Thyroid problems, cold or heat intolerance, polydipsia, polyphagia,
polyuria, changes in skin, hair or nail texture, unexplained weight change,
changes in facial or body hair, change in hat or glove size, use of hormonal
therapy.
13) Hematologic/lymphatic: Bruising, unusual bleeding, fatigue, history of anemia,
last HCT and result, history of blood transfusions, swollen and/or tender glands.
14) Allergic/immunologic: Seasonal allergies, previous allergy testing, potential for
exposure to blood and body fluids, immunized for hepatitis B,
immunosuppression in self or family member, use of steroids.
OBJECTIVE DATA:
A concise report of physical exam findings. Systems (there are 12 systems for
examination):
1. Constitutional (VS: Temp, BP, pulse, height and weight); a statement
describing the patient’s general appearance
2. Eyes
3. Ear, nose, throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integument/lymphatic pertaining to each location
10. Neurologic
11. Psychiatric
12. Hematologic/immunologic
Results of any diagnostic testing available during patient visit.
ASSESSMENT (A):
? List and number the possible diagnoses (problems) you have identified. These
diagnoses are the conclusions you have drawn from the subjective and objective
data.
? Diagnosis must be codable (CPT codes).
? Provide adequate information to justify ordering additional data (e.g., lab, x-ray).
? Do not write that a diagnosis is to be “ruled out.” State the working definitions
(symptoms, probable diagnoses) of patient problems in the following areas:
o Health maintenance
o Acute self-limited problems
o Chronic health problems
In cases where the diagnosis is already established, indicate whether the diagnosis
has the following characteristics: improved, well controlled, resolving, resolved,
inadequately controlled, worsening or failing to change as expected.
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PRAC 6552: Advanced Nurse Practice in Reproductive Health Care Practicum
Note: Inadequately controlled chronic conditions should have a possible etiology written
(e.g., exacerbation, progression, side effects of treatment) if known.
PLAN (P): (The plan should be discussed with and agreed on by the patient.)
The treatment plan includes a wide range of management actions:
? Laboratory test
? Consultation requested and justification
? Medications prescribed (name, dose, route, amount, refills)
? Appliances prescribed
? Lifestyle modifications: diet, activity modification
? Patient education and patient responsibilities (e.g., keeping food diary or BP
record)
? Patient counseling related to lab/diagnostic results, impression, or
recommendations
? Family education
? Details concerning coordination of care: arranging and organizing patient’s
care with other providers and agencies
? Follow-up should be specified with time (in days, weeks, months) and/or
circumstances of return or noted as PRN
Note: Number the plan to correlate with the problem list in the Assessment.
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