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Benchmark Assignment – Academic Clinical SOAP Note

Benchmark Assignment – Academic Clinical SOAP NoteBenchmark Assignment – Academic Clinical SOAP NoteAcademic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.This assignment uses a template. Locate the “Academic SOAP Note Template” on the Student Success Center page under the AGACNP tab.Develop a hospital follow-up progress SOAP note based on a clinical patient from your practicum setting. In your assessment, provide the following:A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.Benchmark Assignment – Academic Clinical SOAP NoteList of at least five systems examined within the past 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.List of all admission diagnostics conducted for this visit or conducted within the past 24 hours.List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.ORDER A PLAGIARISM-FREE PAPER HERETreatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.Discussion of any relevant ethical, legal, or geriatric-specific considerations.Incorporate at least three peer-reviewed articles in the assessment or plan.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.Benchmark – Academic Clinical SOAP Note – RubricCollapse All Benchmark – Academic Clinical SOAP Note – RubricCollapse AllPrimary or Working Diagnosis (B)6 pointsCriteria DescriptionPrimary or Working Diagnosis (C6.2)5. Target6 pointsA one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details.4. Acceptable5.4 pointsA one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided accurately.3. Approaching 4.8 pointsA one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is provided.2. Insufficient3 pointsA one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is incomplete or incorrect.1. Unsatisfactory0 pointsA one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is not provided.Brief Clinical Course (B) 6 pointsCriteria DescriptionBrief Clinical Course (C7.4)5. Target6 pointsA one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete with supporting documentation.Benchmark Assignment – Academic Clinical SOAP Note4. Acceptable5.4 pointsA one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete.3. Approaching 4.8 pointsA one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is supported with minor details missing.2. Insufficient3 pointsA one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is only partially supported.1. Unsatisfactory0 pointsA one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is not provided.Review Of Systems6 pointsCriteria DescriptionReview Of Systems5. Target6 pointsFive systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with thorough details and support.4. Acceptable5.4 pointsFive systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with accurate details and support.3. Approaching 4.8 pointsFive systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided but with minimal detail or support.2. Insufficient3 pointsFive systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are incomplete or incorrect.1. Unsatisfactory0 pointsFive systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are not present.Benchmark Assignment – Academic Clinical SOAP NoteExam6 pointsCriteria DescriptionExam5. Target6 pointsFive systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with thorough details and support.4. Acceptable5.4 pointsFive systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with accurate details and support.3. Approaching 4.8 pointsFive systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided but with minimal detail or support.2. Insufficient3 pointsFive systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are incomplete or incorrect.1. Unsatisfactory0 pointsFive systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are not present.Diagnostics6 pointsCriteria DescriptionDiagnostics5. Target6 pointsDiagnostics within the past 24 hours are provided with thorough details and support.4. Acceptable5.4 pointsDiagnostics within the past 24 hours are provided with accurate details and support.3. Approaching 4.8 pointsDiagnostics within the past 24 hours are provided but with minimal detail or support.2. Insufficient3 pointsDiagnostics within the past 24 hours are incomplete or incorrect.1. Unsatisfactory0 pointsDiagnostics within the past 24 hours are not present.Impression or Assessment6 pointsCriteria DescriptionImpression or Assessment5. Target6 pointsIdentification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with thorough details and support.4. Acceptable5.4 pointsIdentification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with accurate details and support.3. Approaching 4.8 pointsIdentification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided but with minimal detail or support.2. Insufficient3 pointsIdentification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are incomplete or incorrect.1. Unsatisfactory0 pointsIdentification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are not present.Plan (B)3 pointsCriteria DescriptionPlan (C7.5)5. Target3 pointsA treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with thorough details and support.4. Acceptable2.7 pointsA treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with accurate details and support.3. Approaching 2.4 pointsA treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided but with minimal details or support.2. Insufficient1.5 pointsA treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is incomplete or incorrect.1. Unsatisfactory0 pointsA treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is not present.Geriatric Specific Care3 pointsCriteria DescriptionGeriatric Specific Care5. Target3 pointsA discussion of ethical, legal, or geriatric considerations is provided with thorough details and support.4. Acceptable2.7 pointsA discussion of ethical, legal, or geriatric considerations is provided with accurate details and support.3. Approaching 2.4 pointsA discussion of ethical, legal, or geriatric considerations is provided but with minimal details or support.2. Insufficient1.5 pointsA discussion of ethical, legal, or geriatric considerations is incomplete or incorrect.1. Unsatisfactory0 pointsA discussion of ethical, legal, or geriatric considerations is not present.Mechanics of Writing 6 pointsCriteria DescriptionIncludes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.5. Target6 pointsNo mechanical errors are present. Skilled control of language choice and sentence structure are used throughout.4. Acceptable5.4 pointsFew mechanical errors are present. Suitable language choice and sentence structure are used.3. Approaching 4.8 pointsOccasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted.2. Insufficient3 pointsFrequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent.1. Unsatisfactory0 pointsErrors in grammar or syntax are pervasive and impede meaning. Incorrect language choice or sentence structure errors are found throughout. Benchmark Assignment – Academic Clinical SOAP NoteFormat/Documentation 12 pointsCriteria DescriptionUses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.5. Target12 pointsNo errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.4. Acceptable10.8 pointsAppropriate format and documentation are used with only minor errors.3. Approaching 9.6 pointsAppropriate format and documentation are used, although there are some obvious errors.2. Insufficient6 pointsAppropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.1. Unsatisfactory0 pointsAppropriate format is not used. No documentation of sources is provided.Total 60 pointsBenchmark Academic Clinical Soap NoteGrand Canyon UniversityANP 652February 05, 2020Admission Date: 12-03-2019Chief Complaint:This study source was downloaded by 100000800518114 from CourseHero.com on 01-19-2022 10:49:56 GMT -06:00https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ 2 BENCHMARK: ACADEMIC CLINICAL SOAP NOTEPatient c/o worsening SOB since this morning.Background:This is a pleasant 33-year-old obesity Hispanic male who presents to emergency roomand does not go and see any doctor, comes in with some shortness of breath and cough. Pa-tient notes that he has been having shortness of breath with productive cough for a few days.Patient states his wife also notes he has been wheezy however denies any history of COPD,asthma or smoking. Patient does note he works in construction and dry wall however doesuse respirator. Nothing has made symptoms better. Symptoms were worse after walking andshower at home. No eliciting factors have been noted. Symptoms are moderate to severe. Pa-tient does have some productive sputum and intermittent wheezing. Denies any history ofCOPD, asthma, similar illness. Denies any smoking. Denies any hemoptysis. Patient doesnote he works in construction and dry wall however does use respirator.Hospital Medications:❖ acetaminophen, 650 mg= 2 TAB, PO, Q4H (Every 4 hours), PRN❖ Albuterol NEB, 2.5 mg= 3 mL, NEB, TID (3 times a day)❖ Albuterol NEB, 2.5 mg= 3 mL, NEB, Q2H (Every 2 hours), PRN❖ cefTRIAXone 2 g IV Push, Q24 (Every 24 hours)❖ montelukast, 10 mg= 1 TAB, PO, QHS (At bedtime)❖ nitroglycerin, 0.4 mg= 1 TAB, Sublingual, 5MX3 (Every 5 minutes x 3 doses), PRN❖ ondansetron, 4 mg= 2 mL, IV Push, Q4H (Every 4 hours), PRN❖ Saline Flush, 10 mL, IV Push, Q12H (Every 12 hours)❖ Zithromax, 500 mg= 2 TAB, PO, Q24H (Every 24 hours) Review of Systems:Constitutional: No fever, no chills, no sweats, no weakness.Eye: No recent visual problem, icterus, discharge, blurring, double vision.This study source was downloaded by 100000800518114 from CourseHero.com on 01-19-2022 10:49:56 GMT -06:00https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/Benchmark Assignment – Academic Clinical SOAP Notehttps://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ 3 BENCHMARK: ACADEMIC CLINICAL SOAP NOTEEar/Nose/Mouth/Throat: No decreased hearing, ear pain, nasal congestion, sore throat.Respiratory: Dyspnea, + wheezing.Cardiovascular: Chest pain with coughing.Gastrointestinal: Denies nausea or vomitingGenitourinary: No dysuria, hematuria, or pain.Hematological/Lymphatics: No bleeding tendency, swollen lymph glandsEndocrine: No excessive thirst, polyuria, cold intolerance, heat intolerance, excessivehunger.Immunologic: No recurrent fevers, recurrent infections, malaiseMusculoskeletal: No back pain or trauma.Integumentary: No Rash, pruritus, abrasions, breakdown, burns, petechiae, skin lesion.Neurologic: No headache, dizziness, numbness, weakness. Alert and oriented X4.Psychiatric: No sleeping problems, irritability, or mood swings/depression.All other systems are negativeVital Signs:T: 98.7 F TMIN: 98.7 F TMAX: 98.9 F HR: 126 RR: 22 BP: 167/77 SpO2:96% WT: 105 kg BMI: 36.33Physical Examination:General: Well nourished, alert, cooperative, moderate discomfort.HEENT: Normocephalic, oral mucosa is moist, normal sclera, no JVD.Respiratory: Mild wheezes bilaterally, prolonged expiration , respirations non-labored. Car-diovascular: Tachycardic, borderline hypoxemiaGastrointestinal: Soft, no guarding, present bowel sounds, no tenderness.Integumentary: Warm, no rash, skin turgor not decreased.Musculoskeletal: Normal range of motion, no deformity.This study source was downloaded by 100000800518114 from CourseHero.com on 01-19-2022 10:49:56 GMT -06:00https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/Benchmark Assignment – Academic Clinical SOAP Notehttps://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ 4 BENCHMARK: ACADEMIC CLINICAL SOAP NOTENeurologic: CN2-12 intact. No focal deficits. Fluent speech. Alert, Oriented x 4.Psychiatric: Cooperative, appropriate mood & affect.Abnormal Labs/Imaging/ Diagnostic Test Result: 12/03/2019❖ WBC 15.9 (High)❖ Neutrophils 70 % (High)❖ Lymphs 19 % (Low)❖ Neutro Absolute 11.08 (High)❖ Lymph Absolute 3.02 (High)❖ Mono Absolute 1.13 (High)❖ Eos Absolute 0.54 (High)❖ Basophil Absolute 0.06 (High)❖ Glucose 134 (High)❖ Albumin Level 5.1 (High)❖ Total Protein 8.9 (High)❖ AST 56 (High)❖ ALT(SGPT) 86 (High)Influenza B PCR NEGATIVEInfluenza A PCR NEGATIVEDiagnostic Data: CT Chest: CT Angio chest negative for PE, there is bilateral infiltrates present, likely pneumo-nia. Prominent mediastinal lymph nodes likely infectious or inflammatory.Diagnostic Data: EKG:Sinus tachycardia 131 beats per minute. No ST segment elevation or depression, noSTEMI.ASSESSMENT/CLINICAL IMPRESSIONSThis study source was downloaded by 100000800518114 from CourseHero.com on 01-19-2022 10:49:56 GMT -06:00https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ 5 BENCHMARK: ACADEMIC CLINICAL SOAP NOTEHealth Problems:1. SOB R10.92. Community Acquired Pneumonia J18.93. Leukocytosis D72.829Differential Diagnosis:ICD-10 J45.51: Asthma Exacerbation- is an acute or subacute episode of progres-sive worsening of symptoms of asthma, including shortness of breath, wheezing, cough, andchest tightness. Exacerbations are marked by decreases from baseline in objective measuresof pulmonary function, such as peak expiratory flow rate and FEV1 (Epocrate. 2019).PLAN COMPONENT MANAGEMENT:Patients with community-acquired pneumonia often present with cough, fever, chills,fatigue, dyspnea, rigors, and pleuritic chest pain. When a patient presents with suspectedcommunity-acquired pneumonia, the physician should first assess the need for hospitalizationusing a mortality prediction tool, such as the Pneumonia Severity Index, combined with clini-cal judgment (Lutfiyya, Henley, Chang, & Reyburn, 2006). When initially diagnosing andtreating community acquired pneumonia (CAP) the patients’ laboratory results, physical ex-amination findings, and patients’ characteristics description (e.g., age, smoking history,chronic illnesses) will play an important role. Physicians should begin their treatment deci-sions by assessing the need for hospitalization using a prediction tool for increased mortality,such as the Pneumonia Severity combined with clinical judgment (Lutfiyya, Henley, Chang,& Reyburn, 2006). In this patients case the plan included the admission to a medical floorwhich included continuous tele-monitoring, overnight stay of 2 days or more, will follow pa-tients procalcitonin level making to prevent level for increasing possibly leading to sepsis, or-dered CT Angio chest and chest x-ray, continue albuterol treatment as need for shortness ofbreath, continue IV steroids, and empiric antibiotic coverage, deescalate per course. This pa-This study source was downloaded by 100000800518114 from CourseHero.com on 01-19-2022 10:49:56 GMT -06:00https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/Benchmark Assignment – Academic Clinical SOAP Note6 BENCHMARK: ACADEMIC CLINICAL SOAP NOTEtient is considered a low risk patient and could have been treated at home but an admissioninto the hospital was recommended in this case because based on this patient’s current habitswe felt that he pose a higher risk of complication and he would more likely to benefit fromhospitalization interventions (FitzGerald & Gibson, 2006).Disposition/ Discharge Plan:Once a patient with CAP is hospitalized, further management will be dictated by thepatient’s response to initial empiric therapy (Ramirez, 2019). Clinical response should be as-sessed during daily rounds. While various criteria have been proposed to assess clinical re-sponse, we generally look for subjective improvement in cough, sputum production, dyspnea,and chest pain (Ramirez, 2019). Objectively, we assess for resolution of fever and normaliza-tion of heart rate, respiratory rate, oxygenation, and white blood cell count. Generally, pa-tients demonstrate some clinical improvement within 48 to 72 hours. Hospital discharge isappropriate when the patient is clinically stable, can take oral medication, has no other activemedical problems, and has a safe environment for continued care (Ramirez, 2019). Patientsdo not need to be kept overnight for observation following the switch to oral therapy. Earlydischarge based on clinical stability and criteria for switching to oral therapy is encouraged toreduce the risk associated with prolonged hospital stays and unnecessary costs (Ramirez,2019). Although the majority of patients diagnosed with community acquired pneumonia re-cover without complications the elderly population continues to exhibit a significantly highermortality rate than the younger population. In this patient’s case, he stayed in the hospital fora full three days and he was able to return home and manage his care at home.Health Education/ Promotion and Disease Prevention:To prevent community acquired pneumonia the first steps will be to stop smoking ifthe patient is a smoker, then the focus is on receiving influenza and pneumococcal vaccina-tions (Kaysin & Viera, 2016). This patient’s underline condition was asthma. With CAP theThis study source was downloaded by 100000800518114 from CourseHero.com on 01-19-2022 10:49:56 GMT -06:00https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ 7 BENCHMARK: ACADEMIC CLINICAL SOAP NOTEpatient with asthma must get their asthma under control and once this patient is under the careof a practitioner for asthma management he should stay active to help the lungs fight off in-fection for future prevention. Other helpful tips are to wash hand with soap and water often,make sure surfaces in the household is cleaned often, always cover your mouth when cough-ing, try to avoid people who have a cold or the flu, taking and completing medication as di-rected by the provider is very important, and drinking plenty of fluids and getting the properamount of rest helps the body heal. A healthy young person may lead a normal life within aweek of recovery from pneumonia. For others, however, weeks may go by before they getback their usual strength and feeling of well-being. They should not be discouraged from re-turning to work or carrying out their usual activities, but they should be warned to expectsome difficulties. Most important patients with CAP will start to feel better in 48 to 72 hoursbut while at home if the patient t continues a fever after 72 hours, if there is a return of short-ness of breath, patient notice a change in sputum color from clear to rust/ green, or the patientjust does feel better then he/ she needs to return to the emergency room.This study source was downloaded by 100000800518114 from CourseHero.com on 01-19-2022 10:49:56 GMT -06:00https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/Benchmark Assignment – Academic Clinical SOAP Note8 BENCHMARK: ACADEMIC CLINICAL SOAP NOTEReferencesAcute asthma exacerbation in adults. (2019, December). Retrieved from https://online.e-pocrates.com/diseases/4531/Acute-asthma-exacerbation-in-adults/Diagnostic-Ap-proachFitzGerald, J. M., & Gibson, P. G. (2006, November). Asthma exacerbations: Prevention. Re-trieved from https://www.ncbi.nlm.nih.gov/pubmed/17071835Kaysin, A., & Viera, A. J. (2016, November 1). Community-Acquired Pneumonia in Adults:Diagnosis and Management. Retrieved fromhttps://www.aafp.org/afp/2016/1101/p698.htmlLutfiyya, M. N., Henley, E., Chang, L. F., & Reyburn, S. W. (2006, February 1). Diagnosisand Treatment of Community-Acquired Pneumonia. Retrieved from https://www.aaf-p.org/afp/2006/0201/p442.htmlThis study source was downloaded by 100000800518114 from CourseHero.com on 01-19-2022 10:49:56 GMT -06:00https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ 9 BENCHMARK: ACADEMIC CLINICAL SOAP NOTERamirez, J. O. (2019, November 11). Overview of community-acquired pneumonia in adults.Retrieved from https://www.uptodate.com/contents/overview-of-community-ac-quired-pneumonia-in-adults#H2940551536This study source was downloaded by 100000800518114 from CourseHero.com on 01-19-2022 10:49:56 GMT -06:00https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/ Powered by TCPDF (www.tcpdf.org) https://www.coursehero.com/file/54575080/Benchmark-soap-note-ANP-652docx/http://www.tcpdf.orgBenchmark Assignment – Academic Clinical SOAP Note

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