what is a nursing journey? – 2 years ago
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– 2 years ago
Professional nurses must be equipped to critique scholarly literature and discern its value for application to practice. Select one current, quantitative scholarly article related to your PICOT question. Appraise the article using the General Appraisal Overview for All Studies Tool (Melnyk & Fineout…
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Order on TutorsGallery →Professional nurses must be equipped to critique scholarly literature and discern its value for application to practice. Select one current, quantitative scholarly article related to your PICOT question. Appraise the article using the General Appraisal Overview for All Studies Tool (Melnyk & Fineout-Overholt, 2023, Appendix C; see also Box 6.1 in Chapter 6). Summarize your appraisal of the article in your own words.
**Include the following sections**:
1. **Application of Course Knowledge**: Answer all questions/criteria with explanations and detail.
1. Provide an overview of the study
1. Purpose
2. Study design
3. Ethics review
2. Describe the study
1. Research question or hypothesis
2. Study aims
3. Sampling technique, sample size, and characteristics
3. Major variables studied
1. Independent variable
2. Dependent variables
3. How were the data analyzed? Were the statistics used appropriately?
4. Were there any untoward events during the conduct of the study?
4. Explain why and how you could use the study results in your practice to make a difference in client outcomes. If you cannot use the results, why not?
5. Include a complete APA reference and Chamberlain Library permalink for the selected article.
– 2 years ago
– 2 years ago **files (2)** – ## U-SOAP.SEEattached.docx – ## HUInitialMHASOAPNoteTemplate1222.docx **## U-SOAP.SEEattached.docx** Unit 3-Clinical SOAP Note. On Majoy depressive disorder. This week topic is MDD. Please follow attached template and rubric below. Due 1-24-25. Instructions Each week st…
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**files (2)**
– ## U-SOAP.SEEattached.docx
– ## HUInitialMHASOAPNoteTemplate1222.docx
**## U-SOAP.SEEattached.docx**
Unit 3-Clinical SOAP Note. On Majoy depressive disorder. This week topic is MDD. Please follow attached template and rubric below. Due 1-24-25.
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
**Follow the rubric t** o develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
**Note**:
_Grades of Incomplete on this assignment will result in a clinical failure._
All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.
Upload note to TurnItIn plagiarism checker for grade submission.
Program Outcomes
1. Demonstrate critical thinking and holistic caring as an advanced practice
2. Analyze scientific literature for application to selected diagnoses and treatment plans.
3. Synthesize ethical principles into the management and evaluation of healthcare delivery concerns in culturally diverse care settings.
4. Articulate a personal philosophy and framework acknowledging professional and accrediting agency competencies relating to the role and scope of practice of the psychiatric mental health nurse practitioner.
5. Implement the role of the psychiatric mental health nurse practitioner in selected clinical settings.
Course Learning Objectives
By the end of this course, you will be able to:
1. Independently with mentor supervision, apply knowledge of chronic and acute psychiatric mental health disorders using the current edition of the Diagnostic and Statistical Manual for Mental Disorders diagnostic criteria to assess, diagnose and manage the patient populations across the lifespan including a focus on vulnerable populations at risk for mental health disorders.
2. Independently with mentor supervision, integrate complete mental health assessment, interview, history, and physical exam data collection with the knowledge of pathophysiology and psychopathology of psychiatric mental health disorders across the life span to form differential diagnoses and implement therapeutic, patient-centered treatment plans and interventions for patient populations across the lifespan.
3. Independently with mentor supervision, merge traditional and complementary pharmacological/non-pharmaceutical interventions into the treatment and management of psychiatric mental health disorders for patient populations across the lifespan.
4. Independently with mentor supervision, examine, evaluate, and demonstrate professional development in the role of the nurse practitioner in the diagnosis and management of health and wellness as well as acute and chronic psychiatric mental health disorders illnesses for patient populations across the lifespan as a member of an interprofessional team.
5. Independently with mentor supervision, integrate cultural, spiritual, and social competencies into therapeutic patient-centered treatment plans in connection with evidence-based findings to the diagnosis and management of individuals, groups, and families across the lifespan with acute, complex, and chronic psychiatric mental health disorders.
6. Independently with mentor supervision, analyze professional values and core ethical/legal standards into the practice of the Psychiatric Mental Health Nurse Practitioner role with relation to patient/staff safety, quality indicators, and health outcome improvement in the delivery of quality psychiatric mental health care to patients.
7. Identifies with mentor supervision, the highest level of professionalism and accountability for the PMHNP role for transition into clinical practice.
Resources
American Nurses Association & American Psychiatric Nurse Association. (2015).
_Psychiatric–mental health nursing: Scope and standards of practice_(2nd ed.) American Nurses Credentialing. ISBN-13: 978-1558105553 ISBN-10: 1558105557
American Psychiatric Association. (2022).
_Diagnostic and statistical manual of mental disorders_ (5th ed.) text revision (DSM-5 TR). APA Press. ISBN 978-0890425763
Carlat, D. J. (2023).
_The psychiatric interview_ (5th ed.). Philadelphia, PA: Wolters Kluwer. ISBN: 9781975212971
Boland, R., Verduin, M., & Ruiz, P. (2022
_) Kaplan & Sadock’s synopsis of psychiatry_ (12th ed.). Wolters Kluwer. ISBN: 9781975145569
Stahl, S. M. (2022).
_Stahl's essential psychopharmacology: Neuroscientific basis and practical applications_ (5th ed.). Cambridge University Press. ISBN 978-1-108-97163-8
Bickley, L. (2016).
_Bates' Guide to Physical Examination and History-Taking_ (11th ed) [VitalSouce bookshelf version]. https://batesvisualguide.com/. Lippincott Williams & Wilkins: ISBN 1609137620
Corey, G. (2016).
_Theory and practice of counseling and psychotherapy_ (10th ed.). Cengage. ISBN: 9781305263727
Heldt, J. P., MD. (2017).
_Memorable psychopharmacology_. Create Space Independent Publishing Platform. ISBN-13: 978-1-535-28034-1
Johnson, K., & Vanderhoef, D. (2016).
_Psychiatric mental health nurse practitioner review manual_ (4th ed.). American Nurses Association. ISBN: 978-1-935213-79-6
Stahl, S. M. (2020).
_Prescriber's guide: Stahl's essential psychopharmacology_ (7th ed.). Cambridge University Press. ISBN 978-1108926010
·
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[Printable Full Syllabus](https://herzing.instructure.com/courses/43992/files/11084800?wrap=1) [Download Printable Full Syllabus](https://herzing.instructure.com/courses/43992/files/11084800/download?download_frd=1)[PDF]
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**## HUInitialMHASOAPNoteTemplate1222.docx**
## **Initial Psychiatric Interview/SOAP Note Template**
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
| | |
| — | — |
| **Criteria** | **Clinical Notes** |
| | |
| **Informed Consent** | Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) |
| **Subjective** | Verify Patient<br>Name:<br>DOB:<br>Minor:<br>Accompanied by:<br>Demographic:<br>Gender Identifier Note:<br>CC:<br>HPI:<br>Pertinent history in record and from patient: X<br>During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.<br>Patient self-esteem appears fair, no reported feelings of excessive guilt, <br>no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,<br>no reported changes in concentration or memory.<br>Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. <br>Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.<br>SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.<br>Allergies: NKDFA.<br>(medication & food)<br>Past Medical Hx: <br>Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.<br>Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.<br>Surgical history no surgical history reported<br>Past Psychiatric Hx:<br>**Previous psychiatric diagnoses**: none reported. <br> <br>Describes stable course of illness. <br>**Previous medication trials**: none reported.<br> <br>**Safety concerns:**<br>History of Violence<br>to Self: none reported <br> <br>History of Violence t<br>o Others: none reported <br> <br>Auditory Hallucinations:<br>Visual Hallucinations:<br>**Mental health treatment history** discussed:<br> <br>History of outpatient treatment: not reported <br>Previous psychiatric hospitalizations: not reported <br>Prior substance abuse treatment: not reported <br>**Trauma history:** Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.<br> <br>**Substance Use:** Client denies use or dependence on nicotine/tobacco products. <br> <br>Client does not report abuse of or dependence on ETOH, and other illicit drugs.<br>Current Medications: No current medications.<br>(Contraceptives):<br>Supplements:<br>Past Psych Med Trials:<br>Family Medical Hx:<br>Family Psychiatric Hx:<br>Substance use<br>Suicides<br>Psychiatric diagnoses/hospitalization<br>Developmental diagnoses<br>Social History:<br>Occupational History: currently unemployed. Denies previous occupational hx <br>Military service History: Denies previous military hx.<br>Education history: completed HS and vocational certificate <br>Developmental History: no significant details reported.<br>(Childhood History include in utero if available)<br>Legal History: no reported/known legal issues, no reported/known conservator or guardian. <br>Spiritual/Cultural Considerations: none reported.<br>ROS:<br>Constitutional: No report of fever or weight loss. <br>Eyes: No report of acute vision changes or eye pain. <br>ENT: No report of hearing changes or difficulty swallowing. <br>Cardiac: No report of chest pain, edema or orthopnea. <br>Respiratory: Denies dyspnea, cough or wheeze. <br>GI: No report of abdominal pain. <br>GU: No report of dysuria or hematuria. <br>Musculoskeletal: No report of joint pain or swelling. <br>Skin: No report of rash, lesion, abrasions. <br>Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. <br>Hematologic: No report of blood clots or easy bleeding. <br>Allergy: No report of hives or allergic reaction. <br>Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…) |
| _Verify Patient:_ Name, Assigned <br>**identification** number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.<br> <br>_Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview._<br>_HPI:_<br>_, Past Medical and Psychiatric History,_<br>_Current Medications, Previous Psych Med trials,_<br>_Allergies._<br>_Social History, Family History._<br>_Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”_ | |
| **Objective** | **Vital Signs:** Stable<br> <br>Temp:<br> BP:<br> HR:<br> R:<br> O2:<br> Pain:<br> Ht:<br> Wt:<br> BMI:<br> BMI Range:<br>LABS:<br>Lab findings WNL<br>Tox screen: Negative<br>Alcohol: Negative<br>HCG: N/A <br>Physical Exam:<br>MSE:<br>Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.<br>Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self. <br>TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.<br>Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. <br>Judgment appears fair . Insight appears fair<br>The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. |
| _This is where the “facts” are located._<br>_Vitals,_<br>**_**Physical Exam (if performed, will not be performed every visit in every setting)_**<br>_Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results._ | |
| **Assessment** | DSM5 Diagnosis: with ICD-10 codes<br>Dx: – <br>Dx: – <br>Dx: – <br>Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. <br>Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. |
| _Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along_<br>_with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment._<br>_Informed Consent Ability_ | |
| **Plan**<br>(Note some items may only be applicable in the inpatient environment) | Inpatient:<br>Psychiatric. Admits to X as per HPI. <br>Estimated stay 3-5 days <br>Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time. <br>Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.<br>Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: <br>· No changes to current medication, as listed in chart, at this time <br>· or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks. <br>· Psychotherapy referral for CBT<br>Education, including health promotion, maintenance, and psychosocial needs<br>· Importance of medication<br>· Discussed current tobacco use. NRT not indicated. <br>· Safety planning<br>· Discuss worsening sx and when to contact office or report to ED<br>Referrals: endocrinologist for diabetes<br>Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks<br>☒ > 50% time spent counseling/coordination of care.<br>Time spent in Psychotherapy 18 minutes<br>Visit lasted 55 minutes<br>Billing Codes for visit: <br>XX<br>XX<br>XX<br>\_\_\__________________________________________<br>NAME, TITLE<br>Date: Click here to enter a date. Time: X |
**## HUInitialMHASOAPNoteTemplate1222.docx**
## **Initial Psychiatric Interview/SOAP Note Template**
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
| | |
| — | — |
| **Criteria** | **Clinical Notes** |
| | |
| **Informed Consent** | Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) |
| **Subjective** | Verify Patient<br>Name:<br>DOB:<br>Minor:<br>Accompanied by:<br>Demographic:<br>Gender Identifier Note:<br>CC:<br>HPI:<br>Pertinent history in record and from patient: X<br>During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.<br>Patient self-esteem appears fair, no reported feelings of excessive guilt, <br>no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,<br>no reported changes in concentration or memory.<br>Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. <br>Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.<br>SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.<br>Allergies: NKDFA.<br>(medication & food)<br>Past Medical Hx: <br>Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.<br>Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.<br>Surgical history no surgical history reported<br>Past Psychiatric Hx:<br>**Previous psychiatric diagnoses**: none reported. <br> <br>Describes stable course of illness. <br>**Previous medication trials**: none reported.<br> <br>**Safety concerns:**<br>History of Violence<br>to Self: none reported <br> <br>History of Violence t<br>o Others: none reported <br> <br>Auditory Hallucinations:<br>Visual Hallucinations:<br>**Mental health treatment history** discussed:<br> <br>History of outpatient treatment: not reported <br>Previous psychiatric hospitalizations: not reported <br>Prior substance abuse treatment: not reported <br>**Trauma history:** Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.<br> <br>**Substance Use:** Client denies use or dependence on nicotine/tobacco products. <br> <br>Client does not report abuse of or dependence on ETOH, and other illicit drugs.<br>Current Medications: No current medications.<br>(Contraceptives):<br>Supplements:<br>Past Psych Med Trials:<br>Family Medical Hx:<br>Family Psychiatric Hx:<br>Substance use<br>Suicides<br>Psychiatric diagnoses/hospitalization<br>Developmental diagnoses<br>Social History:<br>Occupational History: currently unemployed. Denies previous occupational hx <br>Military service History: Denies previous military hx.<br>Education history: completed HS and vocational certificate <br>Developmental History: no significant details reported.<br>(Childhood History include in utero if available)<br>Legal History: no reported/known legal issues, no reported/known conservator or guardian. <br>Spiritual/Cultural Considerations: none reported.<br>ROS:<br>Constitutional: No report of fever or weight loss. <br>Eyes: No report of acute vision changes or eye pain. <br>ENT: No report of hearing changes or difficulty swallowing. <br>Cardiac: No report of chest pain, edema or orthopnea. <br>Respiratory: Denies dyspnea, cough or wheeze. <br>GI: No report of abdominal pain. <br>GU: No report of dysuria or hematuria. <br>Musculoskeletal: No report of joint pain or swelling. <br>Skin: No report of rash, lesion, abrasions. <br>Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. <br>Hematologic: No report of blood clots or easy bleeding. <br>Allergy: No report of hives or allergic reaction. <br>Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…) |
| _Verify Patient:_ Name, Assigned <br>**identification** number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.<br> <br>_Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview._<br>_HPI:_<br>_, Past Medical and Psychiatric History,_<br>_Current Medications, Previous Psych Med trials,_<br>_Allergies._<br>_Social History, Family History._<br>_Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”_ | |
| **Objective** | **Vital Signs:** Stable<br> <br>Temp:<br> BP:<br> HR:<br> R:<br> O2:<br> Pain:<br> Ht:<br> Wt:<br> BMI:<br> BMI Range:<br>LABS:<br>Lab findings WNL<br>Tox screen: Negative<br>Alcohol: Negative<br>HCG: N/A <br>Physical Exam:<br>MSE:<br>Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.<br>Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self. <br>TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.<br>Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. <br>Judgment appears fair . Insight appears fair<br>The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. |
| _This is where the “facts” are located._<br>_Vitals,_<br>**_**Physical Exam (if performed, will not be performed every visit in every setting)_**<br>_Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results._ | |
| **Assessment** | DSM5 Diagnosis: with ICD-10 codes<br>Dx: – <br>Dx: – <br>Dx: – <br>Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. <br>Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. |
| _Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along_<br>_with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment._<br>_Informed Consent Ability_ | |
| **Plan**<br>(Note some items may only be applicable in the inpatient environment) | Inpatient:<br>Psychiatric. Admits to X as per HPI. <br>Estimated stay 3-5 days <br>Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time. <br>Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.<br>Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: <br>· No changes to current medication, as listed in chart, at this time <br>· or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks. <br>· Psychotherapy referral for CBT<br>Education, including health promotion, maintenance, and psychosocial needs<br>· Importance of medication<br>· Discussed current tobacco use. NRT not indicated. <br>· Safety planning<br>· Discuss worsening sx and when to contact office or report to ED<br>Referrals: endocrinologist for diabetes<br>Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks<br>☒ > 50% time spent counseling/coordination of care.<br>Time spent in Psychotherapy 18 minutes<br>Visit lasted 55 minutes<br>Billing Codes for visit: <br>XX<br>XX<br>XX<br>\_\_\__________________________________________<br>NAME, TITLE<br>Date: Click here to enter a date. Time: X |
**## U-SOAP.SEEattached.docx**
Unit 3-Clinical SOAP Note. On Majoy depressive disorder. This week topic is MDD. Please follow attached template and rubric below. Due 1-24-25.
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
**Follow the rubric t** o develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
**Note**:
_Grades of Incomplete on this assignment will result in a clinical failure._
All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.
Upload note to TurnItIn plagiarism checker for grade submission.
Program Outcomes
1. Demonstrate critical thinking and holistic caring as an advanced practice
2. Analyze scientific literature for application to selected diagnoses and treatment plans.
3. Synthesize ethical principles into the management and evaluation of healthcare delivery concerns in culturally diverse care settings.
4. Articulate a personal philosophy and framework acknowledging professional and accrediting agency competencies relating to the role and scope of practice of the psychiatric mental health nurse practitioner.
5. Implement the role of the psychiatric mental health nurse practitioner in selected clinical settings.
Course Learning Objectives
By the end of this course, you will be able to:
1. Independently with mentor supervision, apply knowledge of chronic and acute psychiatric mental health disorders using the current edition of the Diagnostic and Statistical Manual for Mental Disorders diagnostic criteria to assess, diagnose and manage the patient populations across the lifespan including a focus on vulnerable populations at risk for mental health disorders.
2. Independently with mentor supervision, integrate complete mental health assessment, interview, history, and physical exam data collection with the knowledge of pathophysiology and psychopathology of psychiatric mental health disorders across the life span to form differential diagnoses and implement therapeutic, patient-centered treatment plans and interventions for patient populations across the lifespan.
3. Independently with mentor supervision, merge traditional and complementary pharmacological/non-pharmaceutical interventions into the treatment and management of psychiatric mental health disorders for patient populations across the lifespan.
4. Independently with mentor supervision, examine, evaluate, and demonstrate professional development in the role of the nurse practitioner in the diagnosis and management of health and wellness as well as acute and chronic psychiatric mental health disorders illnesses for patient populations across the lifespan as a member of an interprofessional team.
5. Independently with mentor supervision, integrate cultural, spiritual, and social competencies into therapeutic patient-centered treatment plans in connection with evidence-based findings to the diagnosis and management of individuals, groups, and families across the lifespan with acute, complex, and chronic psychiatric mental health disorders.
6. Independently with mentor supervision, analyze professional values and core ethical/legal standards into the practice of the Psychiatric Mental Health Nurse Practitioner role with relation to patient/staff safety, quality indicators, and health outcome improvement in the delivery of quality psychiatric mental health care to patients.
7. Identifies with mentor supervision, the highest level of professionalism and accountability for the PMHNP role for transition into clinical practice.
Resources
American Nurses Association & American Psychiatric Nurse Association. (2015).
_Psychiatric–mental health nursing: Scope and standards of practice_(2nd ed.) American Nurses Credentialing. ISBN-13: 978-1558105553 ISBN-10: 1558105557
American Psychiatric Association. (2022).
_Diagnostic and statistical manual of mental disorders_ (5th ed.) text revision (DSM-5 TR). APA Press. ISBN 978-0890425763
Carlat, D. J. (2023).
_The psychiatric interview_ (5th ed.). Philadelphia, PA: Wolters Kluwer. ISBN: 9781975212971
Boland, R., Verduin, M., & Ruiz, P. (2022
_) Kaplan & Sadock’s synopsis of psychiatry_ (12th ed.). Wolters Kluwer. ISBN: 9781975145569
Stahl, S. M. (2022).
_Stahl's essential psychopharmacology: Neuroscientific basis and practical applications_ (5th ed.). Cambridge University Press. ISBN 978-1-108-97163-8
Bickley, L. (2016).
_Bates' Guide to Physical Examination and History-Taking_ (11th ed) [VitalSouce bookshelf version]. https://batesvisualguide.com/. Lippincott Williams & Wilkins: ISBN 1609137620
Corey, G. (2016).
_Theory and practice of counseling and psychotherapy_ (10th ed.). Cengage. ISBN: 9781305263727
Heldt, J. P., MD. (2017).
_Memorable psychopharmacology_. Create Space Independent Publishing Platform. ISBN-13: 978-1-535-28034-1
Johnson, K., & Vanderhoef, D. (2016).
_Psychiatric mental health nurse practitioner review manual_ (4th ed.). American Nurses Association. ISBN: 978-1-935213-79-6
Stahl, S. M. (2020).
_Prescriber's guide: Stahl's essential psychopharmacology_ (7th ed.). Cambridge University Press. ISBN 978-1108926010
·
[Learner Resources](https://herzing.instructure.com/courses/43992/files/11084794?wrap=1) [Download Learner Resources](https://herzing.instructure.com/courses/43992/files/11084794/download?download_frd=1)[PDF]
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**## HUInitialMHASOAPNoteTemplate1222.docx**
## **Initial Psychiatric Interview/SOAP Note Template**
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
| | |
| — | — |
| **Criteria** | **Clinical Notes** |
| | |
| **Informed Consent** | Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) |
| **Subjective** | Verify Patient<br>Name:<br>DOB:<br>Minor:<br>Accompanied by:<br>Demographic:<br>Gender Identifier Note:<br>CC:<br>HPI:<br>Pertinent history in record and from patient: X<br>During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.<br>Patient self-esteem appears fair, no reported feelings of excessive guilt, <br>no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,<br>no reported changes in concentration or memory.<br>Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. <br>Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.<br>SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.<br>Allergies: NKDFA.<br>(medication & food)<br>Past Medical Hx: <br>Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.<br>Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.<br>Surgical history no surgical history reported<br>Past Psychiatric Hx:<br>**Previous psychiatric diagnoses**: none reported. <br> <br>Describes stable course of illness. <br>**Previous medication trials**: none reported.<br> <br>**Safety concerns:**<br>History of Violence<br>to Self: none reported <br> <br>History of Violence t<br>o Others: none reported <br> <br>Auditory Hallucinations:<br>Visual Hallucinations:<br>**Mental health treatment history** discussed:<br> <br>History of outpatient treatment: not reported <br>Previous psychiatric hospitalizations: not reported <br>Prior substance abuse treatment: not reported <br>**Trauma history:** Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.<br> <br>**Substance Use:** Client denies use or dependence on nicotine/tobacco products. <br> <br>Client does not report abuse of or dependence on ETOH, and other illicit drugs.<br>Current Medications: No current medications.<br>(Contraceptives):<br>Supplements:<br>Past Psych Med Trials:<br>Family Medical Hx:<br>Family Psychiatric Hx:<br>Substance use<br>Suicides<br>Psychiatric diagnoses/hospitalization<br>Developmental diagnoses<br>Social History:<br>Occupational History: currently unemployed. Denies previous occupational hx <br>Military service History: Denies previous military hx.<br>Education history: completed HS and vocational certificate <br>Developmental History: no significant details reported.<br>(Childhood History include in utero if available)<br>Legal History: no reported/known legal issues, no reported/known conservator or guardian. <br>Spiritual/Cultural Considerations: none reported.<br>ROS:<br>Constitutional: No report of fever or weight loss. <br>Eyes: No report of acute vision changes or eye pain. <br>ENT: No report of hearing changes or difficulty swallowing. <br>Cardiac: No report of chest pain, edema or orthopnea. <br>Respiratory: Denies dyspnea, cough or wheeze. <br>GI: No report of abdominal pain. <br>GU: No report of dysuria or hematuria. <br>Musculoskeletal: No report of joint pain or swelling. <br>Skin: No report of rash, lesion, abrasions. <br>Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. <br>Hematologic: No report of blood clots or easy bleeding. <br>Allergy: No report of hives or allergic reaction. <br>Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…) |
| _Verify Patient:_ Name, Assigned <br>**identification** number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.<br> <br>_Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview._<br>_HPI:_<br>_, Past Medical and Psychiatric History,_<br>_Current Medications, Previous Psych Med trials,_<br>_Allergies._<br>_Social History, Family History._<br>_Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”_ | |
| **Objective** | **Vital Signs:** Stable<br> <br>Temp:<br> BP:<br> HR:<br> R:<br> O2:<br> Pain:<br> Ht:<br> Wt:<br> BMI:<br> BMI Range:<br>LABS:<br>Lab findings WNL<br>Tox screen: Negative<br>Alcohol: Negative<br>HCG: N/A <br>Physical Exam:<br>MSE:<br>Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.<br>Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self. <br>TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.<br>Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. <br>Judgment appears fair . Insight appears fair<br>The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. |
| _This is where the “facts” are located._<br>_Vitals,_<br>**_**Physical Exam (if performed, will not be performed every visit in every setting)_**<br>_Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results._ | |
| **Assessment** | DSM5 Diagnosis: with ICD-10 codes<br>Dx: – <br>Dx: – <br>Dx: – <br>Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. <br>Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. |
| _Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along_<br>_with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment._<br>_Informed Consent Ability_ | |
| **Plan**<br>(Note some items may only be applicable in the inpatient environment) | Inpatient:<br>Psychiatric. Admits to X as per HPI. <br>Estimated stay 3-5 days <br>Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time. <br>Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.<br>Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: <br>· No changes to current medication, as listed in chart, at this time <br>· or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks. <br>· Psychotherapy referral for CBT<br>Education, including health promotion, maintenance, and psychosocial needs<br>· Importance of medication<br>· Discussed current tobacco use. NRT not indicated. <br>· Safety planning<br>· Discuss worsening sx and when to contact office or report to ED<br>Referrals: endocrinologist for diabetes<br>Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks<br>☒ > 50% time spent counseling/coordination of care.<br>Time spent in Psychotherapy 18 minutes<br>Visit lasted 55 minutes<br>Billing Codes for visit: <br>XX<br>XX<br>XX<br>\_\_\__________________________________________<br>NAME, TITLE<br>Date: Click here to enter a date. Time: X |
**## U-SOAP.SEEattached.docx**
Unit 3-Clinical SOAP Note. On Majoy depressive disorder. This week topic is MDD. Please follow attached template and rubric below. Due 1-24-25.
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
**Follow the rubric t** o develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
**Note**:
_Grades of Incomplete on this assignment will result in a clinical failure._
All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.
Upload note to TurnItIn plagiarism checker for grade submission.
Program Outcomes
1. Demonstrate critical thinking and holistic caring as an advanced practice
2. Analyze scientific literature for application to selected diagnoses and treatment plans.
3. Synthesize ethical principles into the management and evaluation of healthcare delivery concerns in culturally diverse care settings.
4. Articulate a personal philosophy and framework acknowledging professional and accrediting agency competencies relating to the role and scope of practice of the psychiatric mental health nurse practitioner.
5. Implement the role of the psychiatric mental health nurse practitioner in selected clinical settings.
Course Learning Objectives
By the end of this course, you will be able to:
1. Independently with mentor supervision, apply knowledge of chronic and acute psychiatric mental health disorders using the current edition of the Diagnostic and Statistical Manual for Mental Disorders diagnostic criteria to assess, diagnose and manage the patient populations across the lifespan including a focus on vulnerable populations at risk for mental health disorders.
2. Independently with mentor supervision, integrate complete mental health assessment, interview, history, and physical exam data collection with the knowledge of pathophysiology and psychopathology of psychiatric mental health disorders across the life span to form differential diagnoses and implement therapeutic, patient-centered treatment plans and interventions for patient populations across the lifespan.
3. Independently with mentor supervision, merge traditional and complementary pharmacological/non-pharmaceutical interventions into the treatment and management of psychiatric mental health disorders for patient populations across the lifespan.
4. Independently with mentor supervision, examine, evaluate, and demonstrate professional development in the role of the nurse practitioner in the diagnosis and management of health and wellness as well as acute and chronic psychiatric mental health disorders illnesses for patient populations across the lifespan as a member of an interprofessional team.
5. Independently with mentor supervision, integrate cultural, spiritual, and social competencies into therapeutic patient-centered treatment plans in connection with evidence-based findings to the diagnosis and management of individuals, groups, and families across the lifespan with acute, complex, and chronic psychiatric mental health disorders.
6. Independently with mentor supervision, analyze professional values and core ethical/legal standards into the practice of the Psychiatric Mental Health Nurse Practitioner role with relation to patient/staff safety, quality indicators, and health outcome improvement in the delivery of quality psychiatric mental health care to patients.
7. Identifies with mentor supervision, the highest level of professionalism and accountability for the PMHNP role for transition into clinical practice.
Resources
American Nurses Association & American Psychiatric Nurse Association. (2015).
_Psychiatric–mental health nursing: Scope and standards of practice_(2nd ed.) American Nurses Credentialing. ISBN-13: 978-1558105553 ISBN-10: 1558105557
American Psychiatric Association. (2022).
_Diagnostic and statistical manual of mental disorders_ (5th ed.) text revision (DSM-5 TR). APA Press. ISBN 978-0890425763
Carlat, D. J. (2023).
_The psychiatric interview_ (5th ed.). Philadelphia, PA: Wolters Kluwer. ISBN: 9781975212971
Boland, R., Verduin, M., & Ruiz, P. (2022
_) Kaplan & Sadock’s synopsis of psychiatry_ (12th ed.). Wolters Kluwer. ISBN: 9781975145569
Stahl, S. M. (2022).
_Stahl's essential psychopharmacology: Neuroscientific basis and practical applications_ (5th ed.). Cambridge University Press. ISBN 978-1-108-97163-8
Bickley, L. (2016).
_Bates' Guide to Physical Examination and History-Taking_ (11th ed) [VitalSouce bookshelf version]. https://batesvisualguide.com/. Lippincott Williams & Wilkins: ISBN 1609137620
Corey, G. (2016).
_Theory and practice of counseling and psychotherapy_ (10th ed.). Cengage. ISBN: 9781305263727
Heldt, J. P., MD. (2017).
_Memorable psychopharmacology_. Create Space Independent Publishing Platform. ISBN-13: 978-1-535-28034-1
Johnson, K., & Vanderhoef, D. (2016).
_Psychiatric mental health nurse practitioner review manual_ (4th ed.). American Nurses Association. ISBN: 978-1-935213-79-6
Stahl, S. M. (2020).
_Prescriber's guide: Stahl's essential psychopharmacology_ (7th ed.). Cambridge University Press. ISBN 978-1108926010
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[Printable Full Syllabus](https://herzing.instructure.com/courses/43992/files/11084800?wrap=1) [Download Printable Full Syllabus](https://herzing.instructure.com/courses/43992/files/11084800/download?download_frd=1)[PDF]
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**## HUInitialMHASOAPNoteTemplate1222.docx**
## **Initial Psychiatric Interview/SOAP Note Template**
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
| | |
| — | — |
| **Criteria** | **Clinical Notes** |
| | |
| **Informed Consent** | Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) |
| **Subjective** | Verify Patient<br>Name:<br>DOB:<br>Minor:<br>Accompanied by:<br>Demographic:<br>Gender Identifier Note:<br>CC:<br>HPI:<br>Pertinent history in record and from patient: X<br>During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.<br>Patient self-esteem appears fair, no reported feelings of excessive guilt, <br>no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,<br>no reported changes in concentration or memory.<br>Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. <br>Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.<br>SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.<br>Allergies: NKDFA.<br>(medication & food)<br>Past Medical Hx: <br>Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.<br>Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.<br>Surgical history no surgical history reported<br>Past Psychiatric Hx:<br>**Previous psychiatric diagnoses**: none reported. <br> <br>Describes stable course of illness. <br>**Previous medication trials**: none reported.<br> <br>**Safety concerns:**<br>History of Violence<br>to Self: none reported <br> <br>History of Violence t<br>o Others: none reported <br> <br>Auditory Hallucinations:<br>Visual Hallucinations:<br>**Mental health treatment history** discussed:<br> <br>History of outpatient treatment: not reported <br>Previous psychiatric hospitalizations: not reported <br>Prior substance abuse treatment: not reported <br>**Trauma history:** Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.<br> <br>**Substance Use:** Client denies use or dependence on nicotine/tobacco products. <br> <br>Client does not report abuse of or dependence on ETOH, and other illicit drugs.<br>Current Medications: No current medications.<br>(Contraceptives):<br>Supplements:<br>Past Psych Med Trials:<br>Family Medical Hx:<br>Family Psychiatric Hx:<br>Substance use<br>Suicides<br>Psychiatric diagnoses/hospitalization<br>Developmental diagnoses<br>Social History:<br>Occupational History: currently unemployed. Denies previous occupational hx <br>Military service History: Denies previous military hx.<br>Education history: completed HS and vocational certificate <br>Developmental History: no significant details reported.<br>(Childhood History include in utero if available)<br>Legal History: no reported/known legal issues, no reported/known conservator or guardian. <br>Spiritual/Cultural Considerations: none reported.<br>ROS:<br>Constitutional: No report of fever or weight loss. <br>Eyes: No report of acute vision changes or eye pain. <br>ENT: No report of hearing changes or difficulty swallowing. <br>Cardiac: No report of chest pain, edema or orthopnea. <br>Respiratory: Denies dyspnea, cough or wheeze. <br>GI: No report of abdominal pain. <br>GU: No report of dysuria or hematuria. <br>Musculoskeletal: No report of joint pain or swelling. <br>Skin: No report of rash, lesion, abrasions. <br>Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. <br>Hematologic: No report of blood clots or easy bleeding. <br>Allergy: No report of hives or allergic reaction. <br>Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…) |
| _Verify Patient:_ Name, Assigned <br>**identification** number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.<br> <br>_Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview._<br>_HPI:_<br>_, Past Medical and Psychiatric History,_<br>_Current Medications, Previous Psych Med trials,_<br>_Allergies._<br>_Social History, Family History._<br>_Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”_ | |
| **Objective** | **Vital Signs:** Stable<br> <br>Temp:<br> BP:<br> HR:<br> R:<br> O2:<br> Pain:<br> Ht:<br> Wt:<br> BMI:<br> BMI Range:<br>LABS:<br>Lab findings WNL<br>Tox screen: Negative<br>Alcohol: Negative<br>HCG: N/A <br>Physical Exam:<br>MSE:<br>Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.<br>Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self. <br>TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.<br>Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. <br>Judgment appears fair . Insight appears fair<br>The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. |
| _This is where the “facts” are located._<br>_Vitals,_<br>**_**Physical Exam (if performed, will not be performed every visit in every setting)_**<br>_Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results._ | |
| **Assessment** | DSM5 Diagnosis: with ICD-10 codes<br>Dx: – <br>Dx: – <br>Dx: – <br>Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. <br>Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. |
| _Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along_<br>_with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment._<br>_Informed Consent Ability_ | |
| **Plan**<br>(Note some items may only be applicable in the inpatient environment) | Inpatient:<br>Psychiatric. Admits to X as per HPI. <br>Estimated stay 3-5 days <br>Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time. <br>Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.<br>Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: <br>· No changes to current medication, as listed in chart, at this time <br>· or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks. <br>· Psychotherapy referral for CBT<br>Education, including health promotion, maintenance, and psychosocial needs<br>· Importance of medication<br>· Discussed current tobacco use. NRT not indicated. <br>· Safety planning<br>· Discuss worsening sx and when to contact office or report to ED<br>Referrals: endocrinologist for diabetes<br>Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks<br>☒ > 50% time spent counseling/coordination of care.<br>Time spent in Psychotherapy 18 minutes<br>Visit lasted 55 minutes<br>Billing Codes for visit: <br>XX<br>XX<br>XX<br>\_\_\__________________________________________<br>NAME, TITLE<br>Date: Click here to enter a date. Time: X |
**Policy Advocacy Assignment (25% of Final Grade)Purpose**: – To formulate written professional communication that advocates for a key nursing issue. – To explore advocacy tools and resources for nurses – To reflect on nursing leadership attributes and personal perspective r/t how each contributes t…
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Order on TutorsGallery →**Policy Advocacy Assignment (25% of Final Grade)Purpose**:
– To formulate written professional communication that advocates for a key nursing issue.
– To explore advocacy tools and resources for nurses
– To reflect on nursing leadership attributes and personal perspective r/t how each contributes to and influences healthcare policy, social justice, and professional nursing practice.
**Goal:**
– To highlight the importance of nurse centered advocacy and identify that all nurses including students have a voice and expertise that is valued and can inspire change.
**Outline of Project.** Policy can seem overwhelming, challenging and a little intimidating; but nurses need to have a voice. I hope this introduction into the world of nursing advocacy will help you become more familiar with the process and strategies that can be employed to make even the smallest of influences. This Assignment is laid out in 3 Essential Parts (each and every part must be completed for credit be awarded). See the grading rubric outlined below for how the grade is determined. Please read through the information carefully, follow the grading rubric, make sure to use appropriate APA formatting (title page and references page). You have a multitude of resources (these can be found with links in this paper below the grading rubric) to help you with this assignment, PLEASE take the time to review them and use them as it will make your life a LOT easier because I have done a lot of the background data gathering for you. **Detailed Outline of Each of the Assignment Parts**
**PART I:** Legislative Representatives and Policies Students identify 2 House of Representatives and 2 Senators from the **state of your choosing**. Students then review 2 bills that are sponsored or co-sponsored by the selected state House of Representatives official(s) and 2 bills that are sponsored or co-sponsored by the selected Senate Representative(s) resulting in a description of 4 total bills (see outline below). Then the students will link these 4 bills to nursing, population, health and rational for choosing. Students _are all assigned a specific state and will find their assigned state in Week 1 in Blackboard under the folder Assigned State for Student’s Advocacy Assignment (_ each student is assigned a different state; if you have trouble locating this or perhaps you were not assigned a state by accident; please ensure to reach out to your instructor).
**PART 2:** Writing a Letter to the Selected RepresentativeStudents will write a persuasive letter to one of the chosen state Representatives identified in Part 1 regarding one of the selected 4 bills (from the 4; just chose 1) that the student feels will have the most impact with a rationale for choosing the selected bill. The letter will be written in a business/personal correspondence style including name, contact information and professional salutation for the receiving party (to whom it may concern is not acceptable). Zip codes for both the student and receiving party must be included to verify that letter is addressed to an appropriate elected official, who represents the student as a constituent. Students will need ensure recipient is the appropriate person for the bill/topic (state vs federal senator, representative, governor, etc.). The uploaded document to BB must follow this format and information. The Florida Nurses Foundation: Legislative Resource Toolkit: on pg 11 (see BB resources) format should be used and is provides you with the template.
**PART 3:** Identify a Policy/Issue and Advocacy Strategy from a Selected Nursing OrganizationStudents will identify a nursing organization of their choice that has a policy advocacy section. Once the student has selected the organization, they will locate the section on advocacy and find their current legislative/advocacy agenda (most recent). There are several nursing organizations to choose from these can be found in your BB resources and in your Patton et al., 2022 textbook (these should be issues that are current and relevant).
3 PAGES
NO MORE THAN 10 % PLAGIARISM ALLOWED
DUE DATE JANUARY 22, 2025
CHECK GRAMMAR AS APPROPRIATE FOR UNIVERSITY LEVEL
REFERENCES 3-4 NO OLDER THAN 5 YEARS WITH CITATIONS
APA STYLE
– 2 years ago
– 2 years ago **files (1)** – ## finalpresentation.docx **## finalpresentation.docx** **_Presentation: Realistic Clinical Case Study_** **_Class: Advanced Family nurse practitioner ADULTS_** For this assignment, you will develop a presentation on a realistic clinical case on a topic that is of inter…
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Order on TutorsGallery →– 2 years ago
**files (1)**
– ## finalpresentation.docx
**## finalpresentation.docx**
**_Presentation: Realistic Clinical Case Study_**
**_Class: Advanced Family nurse practitioner ADULTS_**
For this assignment, you will develop a presentation on a realistic clinical case on a topic that is of interest to you. Develop your presentation based on a clinical case that was seen during your experience or a topic that is of interest to you.
**Content Requirements** You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following:
1.
**Subjective data:** Demographics; Chief Complaint; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem; Medications; Allergies; Past medical history; Family history; Past surgical history; Social history; Review of Systems (ROS)
2.
**Objective data:** Vital signs; Physical exam, Labs (reviewed from the patient's medical records, if no lab/diagnostic tests were done recently to review, you must indicate that to receive credit).
3.
**Assessment:** Differential diagnosis; Primary Diagnosis
4.
**Plan:** Laboratory and diagnostic tests; Pharmacologic treatment plan; non-pharmacologic treatment plan; Anticipatory guidance (primary prevention strategies); Follow up plan.
5.
**Other:** Incorporation of current clinical guidelines; Integration of research articles; Role of the Nurse practitioner
**Submission Instructions:**
· The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references.
· The presentation should consist of 10-15 slides and less than 5 minutes in length.
· Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style (the library has a copy of the APA Manual).
**## finalpresentation.docx**
**_Presentation: Realistic Clinical Case Study_**
**_Class: Advanced Family nurse practitioner ADULTS_**
For this assignment, you will develop a presentation on a realistic clinical case on a topic that is of interest to you. Develop your presentation based on a clinical case that was seen during your experience or a topic that is of interest to you.
**Content Requirements** You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following:
1.
**Subjective data:** Demographics; Chief Complaint; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem; Medications; Allergies; Past medical history; Family history; Past surgical history; Social history; Review of Systems (ROS)
2.
**Objective data:** Vital signs; Physical exam, Labs (reviewed from the patient's medical records, if no lab/diagnostic tests were done recently to review, you must indicate that to receive credit).
3.
**Assessment:** Differential diagnosis; Primary Diagnosis
4.
**Plan:** Laboratory and diagnostic tests; Pharmacologic treatment plan; non-pharmacologic treatment plan; Anticipatory guidance (primary prevention strategies); Follow up plan.
5.
**Other:** Incorporation of current clinical guidelines; Integration of research articles; Role of the Nurse practitioner
**Submission Instructions:**
· The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references.
· The presentation should consist of 10-15 slides and less than 5 minutes in length.
· Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style (the library has a copy of the APA Manual).
The Centers for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of National Quality Forum (NQF) of “never events.” Meaning, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurre…
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Order on TutorsGallery →The Centers for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of National Quality Forum (NQF) of “never events.” Meaning, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurred while a patient was under the care of a healthcare professional.
– Discuss specific examples of “never events” and their impact in your workplace.
– What issues are you considering for your clinical project and why?
– Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
– 2 years ago
The Centers for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of National Quality Forum (NQF) of “never events.” Meaning, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurre…
Immediate access to the full model answer, formatted citations, and rubric breakdown.
Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →The Centers for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of National Quality Forum (NQF) of “never events.” Meaning, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurred while a patient was under the care of a healthcare professional.
– Discuss specific examples of “never events” and their impact in your workplace.
– What issues are you considering for your clinical project and why?
– Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
– 2 years ago
To assess own leadership skills. 1. Determine your preferred leadership style using The Foundation of Nursing Leadership's [Leadership Development – Test One – What is your leadership style?Links to an external site.](http://www.nursingleadership.org.uk/test1.php) 2. Analyze your leadership’s skills…
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Order on TutorsGallery →To assess own leadership skills.
1. Determine your preferred leadership style using The Foundation of Nursing Leadership's [Leadership Development – Test One – What is your leadership style?Links to an external site.](http://www.nursingleadership.org.uk/test1.php)
2. Analyze your leadership’s skills based on your self-assessment.
3. Identify strengths and opportunities for improvement based on your self-assessment.
4. Create an action plan to address self-assessment capitalizing on strengths and addressing opportunities for improvement.
– The paper is to be clear and concise, and students will lose points for improper grammar, punctuation and misspelling.
– The paper is to be 2 – 3 pages in length, excluding the title, abstract and references page.
– Incorporate a minimum of 2 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.
– 2 years ago
To assess own leadership skills. 1. Determine your preferred leadership style using The Foundation of Nursing Leadership's [Leadership Development – Test One – What is your leadership style?Links to an external site.](http://www.nursingleadership.org.uk/test1.php) 2. Analyze your leadership’s skills…
Immediate access to the full model answer, formatted citations, and rubric breakdown.
Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →To assess own leadership skills.
1. Determine your preferred leadership style using The Foundation of Nursing Leadership's [Leadership Development – Test One – What is your leadership style?Links to an external site.](http://www.nursingleadership.org.uk/test1.php)
2. Analyze your leadership’s skills based on your self-assessment.
3. Identify strengths and opportunities for improvement based on your self-assessment.
4. Create an action plan to address self-assessment capitalizing on strengths and addressing opportunities for improvement.
– The paper is to be clear and concise, and students will lose points for improper grammar, punctuation and misspelling.
– The paper is to be 2 – 3 pages in length, excluding the title, abstract and references page.
– Incorporate a minimum of 2 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.
– 2 years ago
The Agency for Healthcare Research and Quality (AHRQ) encourages collaboration across different disciplines to seek solutions that provide a culture of safety for patients. This collaboration must include informatics as part of the interprofessional team. Patient safety is always at the center of th…
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Order on TutorsGallery →The Agency for Healthcare Research and Quality (AHRQ) encourages collaboration across different disciplines to seek solutions that provide a culture of safety for patients. This collaboration must include informatics as part of the interprofessional team. Patient safety is always at the center of the design and adoption of any technology introduced in a patient care setting. Reflect on a recent patient situation and describe three communication tools that were used to provide quality care. How did these communication tools assist the interprofessional team in making decisions for the patient? Provide one example of how technology in this situation can be improved.
Initial discussion question posts should be a minimum of 200 words and include at least two references cited using APA format. Responses to peers or faculty should be 100-150 words and include one reference. Refer to "RN-BSN Discussion Question Rubric" and "RN-BSN Participation Rubric," located in Class Resources, to understand the expectations for initial discussion question posts and participation posts, respectively.
– 2 years ago