Week 3 Focused SOAP Note and Patient Case Presentation.
Week 3 Focused SOAP Note and Patient Case Presentation.
| What do I have to do? | When do I have to do it? |
| Review your Learning Resources. | Days 1–7 |
| Assignment 1: Clinical Hour and Patient Logs | Record your clinical hours and patient encounters in Meditrek by Day 7. |
| Assignment 2: Focused SOAP Note and Patient Case Presentation | Submit by Day 7. |
Introduction Consider the experiences you have had thus far, either in the healthcare workplace or at your practicum site. As you likely know, a nurse’s job does not begin and end with one-to-one patient contact. It includes meetings, documentation, trainings, and collaboration. In particular, the nurse is a member of an interdisciplinary team and must use oral and written communication to inform others of a patient’s status. A central skill of advanced practice nursing, then, is the ability to present a patient’s history, symptoms, diagnosis, and treatment plan to relevant parties involved in treatment. This week, in addition to your Meditrek tracking, you will develop a focused SOAP note and video case presentation on one of the patients you have examined in your clinical practicum. Learning Objectives Students will: Week 3: Focused SOAP Note and Patient Case Presentation.
- Describe clinical hours and patient encounters
- Assess patients across the lifespan in mental health settings
- Formulate differential diagnoses for patients across the lifespan in mental health settings
- Develop plans of care for patients across the lifespan in mental health settings
- Advocate health promotion and patient education strategies across the lifespan
- Develop a case study presentation based on a clinical patient
Learning Resources Required Readings (click to expand/reduce) Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
- Section II. The Psychiatric History (Chapters 14–18)
- Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)
Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. In J. M. Rey & A. Martin (Eds.), IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/content/uploads/A.7-Psychopharmacology-2019.1.pdf Meditrek https://edu.meditrek.com/Default.html Note: Use this link to log into Meditrek to report your clinical hours and patient encounters. Document: Focused SOAP Note Template (Word document) Document: Focused SOAP Note Exemplar (Word document)
Discussion: Interaction Between Nurse Informaticists and Other Specialists
Nature offers many examples of specialization and collaboration. Ant colonies and bee hives are but two examples of nature’s sophisticated organizations. Each thrives because their members specialize by tasks, divide labor, and collaborate to ensure food, safety, and general well-being of the colony or hive. Week 3 Focused SOAP Note and Patient Case Presentation.
Of course, humans don’t fare too badly in this regard either. And healthcare is a great example. As specialists in the collection, access, and application of data, nurse informaticists collaborate with specialists on a regular basis to ensure that appropriate data is available to make decisions and take actions to ensure the general well-being of patients. Week 3: Focused SOAP Note and Patient Case Presentation.
In this Discussion, you will reflect on your own observations of and/or experiences with informaticist collaboration. You will also propose strategies for how these collaborative experiences might be improved. Week 3: Focused SOAP Note and Patient Case Presentation.
To Prepare: Week 3: Focused SOAP Note and Patient Case Presentation.
- Review the Resources and reflect on the evolution of nursing informatics from a science to a nursing specialty. Week 3 Focused SOAP Note and Patient Case Presentation.
- Consider your experiences with nurse Informaticists or technology specialists within your healthcare organization. Week 3 Focused SOAP Note and Patient Case Presentation.
By Day 3 of Week 3
Post a description of experiences or observations about how nurse informaticists and/or data or technology specialists interact with other professionals within your healthcare organization. Suggest at least one strategy on how these interactions might be improved. Be specific and provide examples. Then, explain the impact you believe the continued evolution of nursing informatics as a specialty and/or the continued emergence of new technologies might have on professional interactions. Week 3 Focused SOAP Note and Patient Case Presentation.
By Day 6 of Week 3
Respond to at least two of your colleagues* on two different days, offering one or more additional interaction strategies in support of the examples/observations shared or by offering further insight to the thoughts shared about the future of these interactions. Week 3 Focused SOAP Note and Patient Case Presentation. Week 3 Focused SOAP Note and Patient Case Presentation.
*Note: Throughout this program, your fellow students are referred to as colleagues.
Submission and Grading Information- Week 3: Focused SOAP Note and Patient Case Presentation.
Grading Criteria- Week 3 Focused SOAP Note and Patient Case Presentation.
To access your rubric:
Week 3 Discussion Rubric
Post by Day 3 and Respond by Day 6 of Week 3
To participate in this Discussion:
Week 3 Discussion- Week 3 Focused SOAP Note and Patient Case Presentation.
Laureate Education (Executive Producer). (2012). Data, information, knowledge and wisdom continuum [Multimedia file]. Baltimore, MD: Author. Retrieved from http://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6051/03/mm/continuum/index.html
Public Health Informatics Institute. (2017). Public Health Informatics: “shipping” information for better health [Video file]. Retrieved from https://www.youtube.com/watch?v=q1gNQ9dm0zg.
Public Health Informatics Institute. (2017). Public Health Informatics: knowledge “architecture” [Video file]. Retrieved from https://www.youtube.com/watch?v=sofmUeQkMLU.
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.
- Chapter 25, “The Art of Caring in Technology-Laden Environments” (pp. 525–535)
- Chapter 26, “Nursing Informatics and the Foundation of Knowledge” (pp. 537–551)