What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies

This is the first SOAP Note not due until December 11, 2019 File Name (My patient information Soap Note 3) I have Upload out patient information with the complaint of abdominal pain I’m thinking her diagnosis is Colitis, appendicitis, or Intussusception. I have up loaded two examples and a template. The only thing I think I forgot to address is sleep. Patient normally sleeps 8-9 hours and is awaken several times throughout the past two nights due to abdominal pain. Assignment 1: Practicum - SOAP Note SOAP Note submissions are a way to reflect on your Practicum experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to this week’s Learning Resources for guidance on writing SOAP Notes. Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note: •  Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies. •  Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues. •  Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. •  Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation? By Day 7 Rubric Detail Select Grid View or List View to change the rubric's layout. Name: NURS_6541_Week3_Application1_Rubric •  Grid View •  List View Excellent Good Fair Poor Subjective: CC (1 point) 1 (1%) - 1 (1%) 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) Subjective: Pertinent positives LOCATES (10 points) 9 (9%) - 10 (10%) Includes thorough, accurate, and pertinent positives LOCATES 8 (8%) - 8 (8%) Includes accurate and pertinent positives LOCATES 7 (7%) - 7 (7%) Includes positives LOCATES 0 (0%) - 6 (6%) Does not include positives LOCATES or positives LOCATES are not pertinent Subjective: Pertinent negatives (from ROS) (10 points) 9 (9%) - 10 (10%) Includes thorough, accurate, and pertinent negatives (from ROS) 8 (8%) - 8 (8%) Includes accurate and pertinent negatives (from ROS) 7 (7%) - 7 (7%) Includes negatives (from ROS) 0 (0%) - 6 (6%) Does not include negatives (from ROS) or negatives (from ROS) are not pertinent Subjective: Pertinent PMH, SH, and FH (3 points) 0 (0%) - 3 (3%) Includes thorough, accurate, and pertinent PMH, SH, and FH 0 (0%) - 0 (0%) NA 2 (2%) - 2 (2%) Includes PMH, SH, and FH 0 (0%) - 1 (1%) Does not include PMH, SH, and FH or PMH, SH, and FH are not pertinent Subjective: Medications and drug/food allergies are not included (1 point) 1 (1%) - 1 (1%) Does not include medications and drug/food allergies 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) Includes medications and drug/food allergies Objective: VS including BMI (2 points) 2 (2%) - 2 (2%) Includes VS including BMI 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 1 (1%) Does not include VS including BMI Objective: Heart and lungs (1 point) 0 (0%) - 1 (1%) Includes heart and lungs 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) Does not include heart and lungs Objective: Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. (5 points) 5 (5%) - 5 (5%) Includes thorough explanation of systems or specialty exam techniques that are not necessary to arrive at a diagnosis 4 (4%) - 4 (4%) Includes systems or specialty exam techniques that are not necessary to arrive at a diagnosis 0 (0%) - 0 (0%) NA 0 (0%) - 3 (3%) Does not include systems or specialty exam techniques that are not necessary to arrive at a diagnosis Objective: Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. (10 points) 9 (9%) - 10 (10%) Omits systems or specialty exam techniques that are necessary to arrive at your diagnosis 8 (8%) - 8 (8%) Omits most systems or specialty exam techniques that are necessary to arrive at your diagnosis 7 (7%) - 7 (7%) Omits some systems or specialty exam techniques that are necessary to arrive at your diagnosis 0 (0%) - 6 (6%) Does not omit systems or specialty exam techniques that are necessary to arrive at your diagnosis Objective: Diagnostic test results (2 points) 2 (2%) - 2 (2%) Includes diagnostic test results 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 1 (1%) Does not include diagnostic test results Assessment: Priority Diagnosis (30 points – 10 points for each priority diagnosis. If less than 3 are appropriate to include – simply no other diagnoses to consider – you will receive all 30 points. Please do not “stretch” to find 3 if they are not actual possibilities.) 27 (27%) - 30 (30%) Includes three appropriate priority diagnoses 24 (24%) - 26 (26%) Includes three appropriate priority diagnoses but some are incorrect or missing 22 (22%) - 23 (23%) Includes fewer than three priority diagnoses but some are incorrect or missing 0 (0%) - 21 (21%) Does not include three appropriate diagnoses Plan: Medications discontinued ("d/c lisinopril 10 mg daily”) (1 point) 1 (1%) - 1 (1%) Includes discontinued medications 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) Does not include discontinued medications Plan: Medications started (“start Avapro 150 mg daily”) (2 points) 2 (2%) - 2 (2%) Includes medications started 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 1 (1%) Does not include medications started Plan: Alternative therapies if appropriate (1 point) 0 (0%) - 1 (1%) Includes alternative therapies if appropriate 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) Does not include alternative therapies if appropriate Plan: Health Promotion strategies – patient/family education (3 points) 0 (0%) - 3 (3%) Includes health promotion strategies – patient/family education 0 (0%) - 0 (0%) NA 2 (2%) - 2 (2%) Includes health promotion strategies – patient/family education, but may not be entirely appropriate for the patient/family 0 (0%) - 1 (1%) Does not include health promotion strategies – patient/family education Plan: Disease Prevention strategies with timeframe if appropriate (3 points) 3 (3%) - 3 (3%) Includes disease prevention strategies with timeframe if appropriate 0 (0%) - 0 (0%) NA 2 (2%) - 2 (2%) Includes disease prevention strategies, but does not include timeframe or disease prevention strategies are not appropriate 0 (0%) - 1 (1%) Does not include disease prevention strategies Plan: Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months) (3 points) 3 (3%) - 3 (3%) Includes appropriate diagnostic tests ordered with timeframe 0 (0%) - 0 (0%) NA 2 (2%) - 2 (2%) Includes diagnostic tests but they may not be appropriate, or the timeframe is incorrect or not included 0 (0%) - 1 (1%) Does not include diagnostic tests Plan: Referrals or consultations if appropriate (1 point) 1 (1%) - 1 (1%) Includes referrals or consultations if appropriate 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) Does not include referrals or consultations if appropriate Plan: Follow-up interval (1 point) 1 (1%) - 1 (1%) Includes follow-up interval 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) NA 0 (0%) - 0 (0%) Does not include follow-up interval Reflection Notes: What did you learn from this experience? Any ah-ha’s? (10 points) 0 (0%) - 10 (10%) Response includes thoughtful and insightful explanation of significant learnings 8 (8%) - 8 (8%) Response includes thoughtful and insightful explanation of learnings 7 (7%) - 7 (7%) Response includes explanation of learnings 0 (0%) - 6 (6%) Response does not include explanation of learnings Total Points: 100 Name: NURS_6541_Week3_Application1_Rubric

ANSWER. PAPER DETAILS
Academic Level	Masters
Subject Area	Nursing
Paper Type	Admission - Application Essay
Number of Pages	10 Page(s)/2750 words
Sources	5
Format	APA
Spacing	Double Spaced

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