Tag: Pathophysiology & Pharmacology

  • [Solved] NUR 514 Clinical discussion 3

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    Describe your clinical experience for this week. – Did you face any challenges, any success? If so, what were they? – Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales. – Mention the …

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    Assignment Prompt & Instructions

    Describe your clinical experience for this week.

    – Did you face any challenges, any success? If so, what were they?
    – Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
    – Mention the health promotion intervention for this patient.
    – What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?
    – Support your plan of care with the current peer-reviewed research guideline.

    **Submission Instructions:**

    – Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

    – 2 years ago

  • [Solved] NUR 501 Assign Wk3

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    I need help with my assignments – 2 years ago **files (1)** – ## NUR501AssignWk3.pdf **## NUR501AssignWk3.pdf** 501 Assignment Week3 Middle Range Theory Utilization & Application Paper Goal: Analyze and evaluate a middle range theory. You will select a middle range theory and identify application of…

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    Assignment Prompt & Instructions

    I need help with my assignments

    – 2 years ago

    **files (1)**

    – ## NUR501AssignWk3.pdf

    **## NUR501AssignWk3.pdf**

    501 Assignment Week3

    Middle Range Theory Utilization & Application Paper

    Goal:

    Analyze and evaluate a middle range theory.  You will select a middle range theory and
    identify application of nursing theories into clinical practice.

    Content Requirements:

    1. Components of the theory

    ◦ Discuss the major concepts of the theory

    ◦ Philosophical basis or worldview change, advancing health

    2. Structural aspects of the theory

    ◦ Discuss the framework of the theory.

    3. Identify an area of your practice where this theory could be applicable

    ◦ What question does the theory help to answer?

    ◦ Describe the area of interest in relationship to the theory/theoretical

    model.

    ◦ Is it appropriate for the practice setting and is it applicable?

    ◦ Discuss the strength and weakness of the theory. If there is weakness,

    discuss what makes it difficult to be used in practice.

    4. Use of theory in clinical practice.

    ◦ Performing a literature review is essential to completing this section. If
    there is no literature available about the application of this theory in
    practice, address reason(s) why based on your findings.

    5. Evaluation of theory

    ◦ Is this theory used to understand and apply into practice?

    ◦ What difficulties did you encounter or would anticipate encountering in

    using this theory?

    ◦ What would make this theory more usable or applicable to practice?

    Submission Instructions:

    • The paper is to be clear and concise and students will lose points for improper
    grammar, punctuation and misspelling.

    • The paper should be formatted per current APA and references should be
    current (published within last five years) scholarly journal articles or primary legal
    sources (statutes, court opinions.)

    • The paper is to be 3 – 5 pages in length, excluding the title, abstract and
    references page.

    • Incorporate a minimum of 3 current (published within 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 current APA
    style.

    **## NUR501AssignWk3.pdf**

    501 Assignment Week3

    Middle Range Theory Utilization & Application Paper

    Goal:

    Analyze and evaluate a middle range theory.  You will select a middle range theory and
    identify application of nursing theories into clinical practice.

    Content Requirements:

    1. Components of the theory

    ◦ Discuss the major concepts of the theory

    ◦ Philosophical basis or worldview change, advancing health

    2. Structural aspects of the theory

    ◦ Discuss the framework of the theory.

    3. Identify an area of your practice where this theory could be applicable

    ◦ What question does the theory help to answer?

    ◦ Describe the area of interest in relationship to the theory/theoretical

    model.

    ◦ Is it appropriate for the practice setting and is it applicable?

    ◦ Discuss the strength and weakness of the theory. If there is weakness,

    discuss what makes it difficult to be used in practice.

    4. Use of theory in clinical practice.

    ◦ Performing a literature review is essential to completing this section. If
    there is no literature available about the application of this theory in
    practice, address reason(s) why based on your findings.

    5. Evaluation of theory

    ◦ Is this theory used to understand and apply into practice?

    ◦ What difficulties did you encounter or would anticipate encountering in

    using this theory?

    ◦ What would make this theory more usable or applicable to practice?

    Submission Instructions:

    • The paper is to be clear and concise and students will lose points for improper
    grammar, punctuation and misspelling.

    • The paper should be formatted per current APA and references should be
    current (published within last five years) scholarly journal articles or primary legal
    sources (statutes, court opinions.)

    • The paper is to be 3 – 5 pages in length, excluding the title, abstract and
    references page.

    • Incorporate a minimum of 3 current (published within 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 current APA
    style.

  • [Solved] Rwh blank

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    Rwh blank answer continuation 38 pages – 2 years ago **files (3)** – ## FinalIRB.docx – FinalWrittenDeliverableTemplate3.2412.docx – Wilkerson1.23.25markup.docx **## FinalIRB.docx** ![](https://www.sweetstudy.com/questions/rwh-blank) **HLC** **Ac** **c** **redi** **t** **ation** **E** **v** **i** **…

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    Assignment Prompt & Instructions

    Rwh blank answer continuation 38 pages

    – 2 years ago

    **files (3)**

    – ## FinalIRB.docx

    – FinalWrittenDeliverableTemplate3.2412.docx
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    **## FinalIRB.docx**

    ![](https://www.sweetstudy.com/questions/rwh-blank)

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    **Title: Implementing assessment tool which measures depression, anxiety and stress in a Outpatient Mental health Private Practice**

    **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval**

    Herzing University’s Institutional Review Board (IRB) reviews all student quality improvement or innovation project protocol requests to determine if it is human subject research that meets definitions in The Common Rule and therefore requires review and oversight by the IRB. It is the investigator’s responsibility to give complete information regarding the planned quality improvement processes. After submitting the application, the IRB will notify the applicant, in writing, of its decision or if additional information is needed.

    **Checklist**

    Please make sure to submit the following items along with this application for your submission:

    ☐ This application with signatures from you and your DNP Project Faculty

    ☐ A copy of all questionnaires and surveys, if used

    ☐ A copy of your CITI Certification (free certification for Herzing affiliates through Canvas)

    ☐ A copy of the application and approval letter from any external IRB (
    _if applicable_)

    ☐ Letter of approval from the Program Chair of the affiliated institution (
    _if applicable_)

    ![](https://www.sweetstudy.com/questions/rwh-blank)

    **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval**

    **Step 1: Your Information**

    | | |
    | — | — |
    | Project Title: | **Implementing assessment tool which measures depression, anxiety and stress in a Outpatient Mental health Private Practice** |
    | Doctorate Student Name: | Ramona Wilkerson |
    | Check One: | X Herzing University Student<br>☐ Student not affiliated with Herzing University – list institution this project is affiliated with: |
    | Email: | [rawilkerson@herzing.edu](mailto:rawilkerson@herzing.edu) |
    | Primary Phone Number: | 201-706-1511 |

    **Step 2: Location, Faculty, and Date Information**

    | | |
    | — | — |
    | Location/Sponsor: | Hudson Regional Hospital |
    | Faculty Information: | Faculty Name: Colleen Bartlett |
    | | Faculty Email:cbartlett@herzing.edu |
    | | Faculty Phone:<br>352-428-7472 |
    | Anticipated Start Date: | 2-1-24 |
    | Anticipated Completion Date: | 5-1-24 |

    **Step 3: Aim Statement Overview**

    **Aim Statement**

    | |
    | — |
    | Aim Statement<br>Key elements of the aim statement needed to be included:<br>1. What? What’s the problem or opportunity? 2. How much? By how much will you improve? Or<br>“how good” do you want to get? 3. By when? What is the date by which you will achieve the level of improvement you’ve set out to accomplish? 4. For whom? Who is the customer or population who will benefit from the improvement? 5. Where? What are the boundaries of the process or system you’re trying to improve? Where does it begin and end? |
    | Over the course of 8 weeks, this project will help to fill the gap which currently exists in the assessment of stress in outpatients in our clinic. Through administering the Depression, Anxiety, and Stress Scale (DASS21), we aim at conducting a more organized approach to evaluating stress prevalence in our patients (Ali, et al., 2022). Therefore, the aim will be to revolutionize patient care and satisfaction in routine practice through stress assessment, which, in turn, will enable proffering of appropriate psychotherapy stress remedies to patients. By week eight from the initiation of the project, we intend to review the patient outcomes as well as satisfaction rate and compare it with the initial parameters to note the impact of improvement. The direct target recipients of this improvement effort are the patient with mental illness that seek outpatient services from our practice. This project includes all facets of the stress assessment process, from incorporating stress assessment in to overall patient assessment, to providing adequate psychotherapy to stressed out patients, and ensuring the best quality of care for our patient panels (Halford, & Frost, 2021). |

    | |
    | — |
    | |

    **Instituti**

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    | — |
    | **Project Overview**<br>Please provide a summary of the proposed quality improvement or innovation project including the purpose, proposed strategy to be utilized, proposed project measures that will be utilized to evaluate outcomes, and the anticipated/desired outcomes.<br>Overview of the problem <br>Stress as a concept is widely discussed and known to be the major factor affecting mental health globally. They are detrimental to the individual’s overall well-being and can lead to certain mental disorders like depression and anxiety disorders (WHO, 2022). Chronic stress worsens a patient’s symptoms in case of having some diagnosed psychiatric disorder, and acute stress may result in the creation of a new disorder if not addressed (American Psychiatry Association [APA], 2022).<br>Local Problem in Practice<br>Stress is an issue that is often present in the lives of many of the patients in our outpatient mental clinic, an independent Psychiatric practice. It has been seen that the patients used to complain and the doctors and other health care professionals who attended them also noticed that the various patients seemed highly stressed and anxious. Based on patient input records kept at the internal clinic, it is established that about 60% of patients show their stress levels ranging from moderate to severe during clinical evaluation and they have higher chances of being diagnosed with depression or anxiety disorders (Smith, 2023).<br>Purpose of the Project<br>The aim of this project is to pilot the use of the Depression, Anxiety, and Stress Scale (DASS21) and manage patient stress in a private practice outpatient mental health clinic. When implemented into practice, the project involves the identification and management of stress-illness, with the intention of optimizing the patient’s overall health outcomes about their mental health diagnoses.<br>Proposed Strategy<br>· Implementation of DASS21: Implement the DASS21 tool for the initial patient assessment and subsequent follow-up to quantify stress, anxiety, and depression scores.<br>· Training Staff: Trials and methods: Educate healthcare providers in the practice using the DASS21 in the administration and comprehension of results.<br>· Integration into Routine Care: Extend the use of DASS21 assessment to incorporate it into standard patient evaluations by using it at various patient encounters.<br>· Data Collection and Analysis: Quantitative patient data related to stress should be gathered before and after the use of DASS21. Age and other characteristics of the patients should also be described and compared between the two groups to determine if the intervention improved the outcomes of the patients.<br>Evaluative Measures<br>Pre- and Post-Implementation Stress Levels: Analyze the stress patient’s self-assessment using the scale before and after the application of the DASS21 tool.<br>Patient Satisfaction: Patient satisfaction can also be assessed through using surveys and feedback forms with the DASS21 patient’s tool (Beaufort, et al., 2017).<br>Clinical Outcomes: This will look at the degree of clinical improvement compared to baseline using medical documentation of patients’ status and follow-up surveys where the patients’ levels of depression and anxiety have presumably dropped.<br>Desired Outcomes<br>· Reduction in Stress Levels: Reduce the inhabitants’ reported tension points for patients to a very low level.<br>· Improved Mental Health: Improve general concern regarding possible depression and anxiety from stress management.<br>· Increased Patient Satisfaction: Improve the number of patients who are satisfied with the mental health services delivered by the organization.<br>· Enhanced Clinical Practice: Enhance patient care by adopting a validated instrument for stress evaluation as well as monitoring the effectiveness of clinical interventions for handling stress.<br>References <br>World Health Organization. (2022). World mental health report: Transforming mental health for all.<br>American Psychological Association. (2022). Stress in America. <br>[https://archive.hshsl.umaryland.edu/handle/10713/20295](https://archive.hshsl.umaryland.edu/handle/10713/20295)<br>Beaufort, I. N., De Weert-Van Oene, G. H., Buwalda, V. A., De Leeuw, J. R. J., & Goudriaan, A. E. (2017). The depression, anxiety and stress scale (DASS-21) as a screener for depression in substance use disorder inpatients: a pilot study. <br>_European addiction research_, <br>_23_(5), 260-268. <br>[https://karger.com/ear/article/23/5/260/119698/The-Depression-Anxiety-and-Stress-Scale-DASS-21-as](https://karger.com/ear/article/23/5/260/119698/The-Depression-Anxiety-and-Stress-Scale-DASS-21-as)<br>. |
    | **QI Framework**<br>Please provide an overview of the framework that will be utilized in the proposed project (e.g. KTA, PDSA, ADKAR, Lean, Six Sigma, DMAIC, etc.). |
    | The development of the suggested quality improvement plan is targeting the optimization of, and increasing patient satisfaction in an outpatient mental health private practice through the implementation of stress assessment via Depression, Anxiety, and Stress Scale 21. This is a comprehensive stress assessment project where the aim is to screen patient populations for specific stress levels and where respective psychotherapeutic stress reduction approaches will be used to minimize stress and enhance quality of life. In addressing this plan, an important approach is to incorporate the DASS21 scale into the basic assessment of patients as well as their follow-up visits to guarantee a systematic assessment of patients’ stress levels (D’Amico, et al., 2024). The shifts in the patient outcomes to be employed in the proposed project pertain to patients’ perceived stress levels, depression, and anxiety levels before and after the implementation of the stress assessment tool, in addition to patients’ satisfaction with the use of the stress assessment tool. The expected impact is expected to be the increased percentage of patients who will be relieved from stress, continued emotional well-being, and overall satisfaction with outpatient mental health services offered at the organization. |

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    | — |
    | **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval**<br>Sources<br>Halford, W. K., & Frost, A. D. (2021). Depression anxiety stress scale-10: A brief measure for routine psychotherapy outcome and progress assessment. <br>_Behaviour Change_, <br>_38_(4), 221-234.<br>[https://www.cambridge.org/core/journals/behaviour-change/article/abs/depression-anxiety-stress-scale10-a-brief-measure-for-routine-psychotherapy-outcome-and-progress-assessment/2259B3A2EB360EE3BD007AAFCD73ED70](https://www.cambridge.org/core/journals/behaviour-change/article/abs/depression-anxiety-stress-scale10-a-brief-measure-for-routine-psychotherapy-outcome-and-progress-assessment/2259B3A2EB360EE3BD007AAFCD73ED70)<br>Ali, A. M., Hori, H., Kim, Y., & Kunugi, H. (2022). The Depression Anxiety Stress Scale 8-items expresses robust psychometric properties as an ideal shorter version of the Depression Anxiety Stress Scale 21 among healthy respondents from three continents. <br>_Frontiers in psychology_, <br>_13_, 799769. <br>[https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2022.799769/full](https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2022.799769/full)<br>![](https://www.sweetstudy.com/questions/rwh-blank)D’Amico, F., Navarrete, J., Montero-Marín, J., Cardeñosa-Valera, E., Navarro-Gil, M., Pérez-Aranda, A., … & Luciano, J. V. (2024). Cost-utility of attachment-based compassion therapy (ABCT) and mindfulness-based stress reduction (MBSR) in the management of depressive, anxious, and adjustment disorders in mental health settings: Economic evaluation alongside a randomized controlled trial. <br>_Mindfulness_, <br>_15_(3), 559-569. <br>[https://link.springer.com/article/10.1007/s12671-024-02319-4](https://link.springer.com/article/10.1007/s12671-024-02319-4) |

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    | **Data Security**<br>**Please provide a description of your data security plan for both physical and electronic data that**<br>**includes protected or identifying personal information. Include where the data will be stored, the**<br>**security of the location or computer system, the length of retention of the data, and the method**<br>**of disposition of old data.**<br>Regarding data protection, the necessary precautions shall be observed relating to paper documents that contain protected or identifying personal information as well as electronic records. Paper-based records will be secured in a locked cabinet or file, and digital records will be saved in password-protected computers only those persons have access who are concerned with it. This system will not be open to the public; access to all the departments will be allowed based on the access code and privileges granted to users. Secured updates or patches will be offered after each period to help in the protection of the system. Any accompanying physical documents will be secured in locked cabinets in an office only to be accessed by authorized personnel. Use of these cabinets will be limited and the keys shall be kept safely under lock and key by the authorized personnel.<br>As for the data retention period, the company will meet legal and industry standards concerning the data retention period with a concrete retention period defined in the data retention policy. The last point entails data disposal where the data is no longer useful or has aged out of the retention period set for it; it shall be deleted using standard methods of data disposal. Hard copy documents will be expelled using a cross-cut shredder for the destruction of any sensitive information. Digital data will be erased from the program by employing careful measures such as digital shredding and overwriting.<br>Additional daily, weekly, monthly, and annual checks are proposed to perform verification of the adherence to the data security requirements and to investigate possible threats. Specific personnel in each center will be tasked with conducting these audits from time to time and any issues arising out of this process will be addressed to minimize risks to the integrity of data. Finally, training in data security measures and guidelines will be provided to all employees to guard against violations of rules as well as to reduce cases of data leakage or instances in which unauthorized individuals gain access to such data. |
    | |

    **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project ApprovalStep 4: Acknowledgement of Responsibilities and Signatures**

    Please note that:

    · Any data collected from Herzing University students, alumni, faculty and/or staff and/or any other constituents for purposes of this project is proprietary. Any publication of findings may not identify or implicate Herzing University. Any external report produced on findings generated by this study, including any presentation or publication, may not identify, reference or implicate Herzing University in any way.

    · Upon completion of the project, a copy of the final deliverable will be submitted to Herzing University.

    · Any additional publications or presentations produced based upon this project will be submitted to Herzing University.

    I certify to the best of my knowledge the information presented is an accurate reflection of the proposed research project.

    ![](https://www.sweetstudy.com/questions/rwh-blank)Date: 6-9-24

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    **## FinalIRB.docx**

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    **Title: Implementing assessment tool which measures depression, anxiety and stress in a Outpatient Mental health Private Practice**

    **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval**

    Herzing University’s Institutional Review Board (IRB) reviews all student quality improvement or innovation project protocol requests to determine if it is human subject research that meets definitions in The Common Rule and therefore requires review and oversight by the IRB. It is the investigator’s responsibility to give complete information regarding the planned quality improvement processes. After submitting the application, the IRB will notify the applicant, in writing, of its decision or if additional information is needed.

    **Checklist**

    Please make sure to submit the following items along with this application for your submission:

    ☐ This application with signatures from you and your DNP Project Faculty

    ☐ A copy of all questionnaires and surveys, if used

    ☐ A copy of your CITI Certification (free certification for Herzing affiliates through Canvas)

    ☐ A copy of the application and approval letter from any external IRB (
    _if applicable_)

    ☐ Letter of approval from the Program Chair of the affiliated institution (
    _if applicable_)

    ![](https://www.sweetstudy.com/questions/rwh-blank)

    **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval**

    **Step 1: Your Information**

    | | |
    | — | — |
    | Project Title: | **Implementing assessment tool which measures depression, anxiety and stress in a Outpatient Mental health Private Practice** |
    | Doctorate Student Name: | Ramona Wilkerson |
    | Check One: | X Herzing University Student<br>☐ Student not affiliated with Herzing University – list institution this project is affiliated with: |
    | Email: | [rawilkerson@herzing.edu](mailto:rawilkerson@herzing.edu) |
    | Primary Phone Number: | 201-706-1511 |

    **Step 2: Location, Faculty, and Date Information**

    | | |
    | — | — |
    | Location/Sponsor: | Hudson Regional Hospital |
    | Faculty Information: | Faculty Name: Colleen Bartlett |
    | | Faculty Email:cbartlett@herzing.edu |
    | | Faculty Phone:<br>352-428-7472 |
    | Anticipated Start Date: | 2-1-24 |
    | Anticipated Completion Date: | 5-1-24 |

    **Step 3: Aim Statement Overview**

    **Aim Statement**

    | |
    | — |
    | Aim Statement<br>Key elements of the aim statement needed to be included:<br>1. What? What’s the problem or opportunity? 2. How much? By how much will you improve? Or<br>“how good” do you want to get? 3. By when? What is the date by which you will achieve the level of improvement you’ve set out to accomplish? 4. For whom? Who is the customer or population who will benefit from the improvement? 5. Where? What are the boundaries of the process or system you’re trying to improve? Where does it begin and end? |
    | Over the course of 8 weeks, this project will help to fill the gap which currently exists in the assessment of stress in outpatients in our clinic. Through administering the Depression, Anxiety, and Stress Scale (DASS21), we aim at conducting a more organized approach to evaluating stress prevalence in our patients (Ali, et al., 2022). Therefore, the aim will be to revolutionize patient care and satisfaction in routine practice through stress assessment, which, in turn, will enable proffering of appropriate psychotherapy stress remedies to patients. By week eight from the initiation of the project, we intend to review the patient outcomes as well as satisfaction rate and compare it with the initial parameters to note the impact of improvement. The direct target recipients of this improvement effort are the patient with mental illness that seek outpatient services from our practice. This project includes all facets of the stress assessment process, from incorporating stress assessment in to overall patient assessment, to providing adequate psychotherapy to stressed out patients, and ensuring the best quality of care for our patient panels (Halford, & Frost, 2021). |

    | |
    | — |
    | |

    **Instituti**

    | |
    | — |
    | **Project Overview**<br>Please provide a summary of the proposed quality improvement or innovation project including the purpose, proposed strategy to be utilized, proposed project measures that will be utilized to evaluate outcomes, and the anticipated/desired outcomes.<br>Overview of the problem <br>Stress as a concept is widely discussed and known to be the major factor affecting mental health globally. They are detrimental to the individual’s overall well-being and can lead to certain mental disorders like depression and anxiety disorders (WHO, 2022). Chronic stress worsens a patient’s symptoms in case of having some diagnosed psychiatric disorder, and acute stress may result in the creation of a new disorder if not addressed (American Psychiatry Association [APA], 2022).<br>Local Problem in Practice<br>Stress is an issue that is often present in the lives of many of the patients in our outpatient mental clinic, an independent Psychiatric practice. It has been seen that the patients used to complain and the doctors and other health care professionals who attended them also noticed that the various patients seemed highly stressed and anxious. Based on patient input records kept at the internal clinic, it is established that about 60% of patients show their stress levels ranging from moderate to severe during clinical evaluation and they have higher chances of being diagnosed with depression or anxiety disorders (Smith, 2023).<br>Purpose of the Project<br>The aim of this project is to pilot the use of the Depression, Anxiety, and Stress Scale (DASS21) and manage patient stress in a private practice outpatient mental health clinic. When implemented into practice, the project involves the identification and management of stress-illness, with the intention of optimizing the patient’s overall health outcomes about their mental health diagnoses.<br>Proposed Strategy<br>· Implementation of DASS21: Implement the DASS21 tool for the initial patient assessment and subsequent follow-up to quantify stress, anxiety, and depression scores.<br>· Training Staff: Trials and methods: Educate healthcare providers in the practice using the DASS21 in the administration and comprehension of results.<br>· Integration into Routine Care: Extend the use of DASS21 assessment to incorporate it into standard patient evaluations by using it at various patient encounters.<br>· Data Collection and Analysis: Quantitative patient data related to stress should be gathered before and after the use of DASS21. Age and other characteristics of the patients should also be described and compared between the two groups to determine if the intervention improved the outcomes of the patients.<br>Evaluative Measures<br>Pre- and Post-Implementation Stress Levels: Analyze the stress patient’s self-assessment using the scale before and after the application of the DASS21 tool.<br>Patient Satisfaction: Patient satisfaction can also be assessed through using surveys and feedback forms with the DASS21 patient’s tool (Beaufort, et al., 2017).<br>Clinical Outcomes: This will look at the degree of clinical improvement compared to baseline using medical documentation of patients’ status and follow-up surveys where the patients’ levels of depression and anxiety have presumably dropped.<br>Desired Outcomes<br>· Reduction in Stress Levels: Reduce the inhabitants’ reported tension points for patients to a very low level.<br>· Improved Mental Health: Improve general concern regarding possible depression and anxiety from stress management.<br>· Increased Patient Satisfaction: Improve the number of patients who are satisfied with the mental health services delivered by the organization.<br>· Enhanced Clinical Practice: Enhance patient care by adopting a validated instrument for stress evaluation as well as monitoring the effectiveness of clinical interventions for handling stress.<br>References <br>World Health Organization. (2022). World mental health report: Transforming mental health for all.<br>American Psychological Association. (2022). Stress in America. <br>[https://archive.hshsl.umaryland.edu/handle/10713/20295](https://archive.hshsl.umaryland.edu/handle/10713/20295)<br>Beaufort, I. N., De Weert-Van Oene, G. H., Buwalda, V. A., De Leeuw, J. R. J., & Goudriaan, A. E. (2017). The depression, anxiety and stress scale (DASS-21) as a screener for depression in substance use disorder inpatients: a pilot study. <br>_European addiction research_, <br>_23_(5), 260-268. <br>[https://karger.com/ear/article/23/5/260/119698/The-Depression-Anxiety-and-Stress-Scale-DASS-21-as](https://karger.com/ear/article/23/5/260/119698/The-Depression-Anxiety-and-Stress-Scale-DASS-21-as)<br>. |
    | **QI Framework**<br>Please provide an overview of the framework that will be utilized in the proposed project (e.g. KTA, PDSA, ADKAR, Lean, Six Sigma, DMAIC, etc.). |
    | The development of the suggested quality improvement plan is targeting the optimization of, and increasing patient satisfaction in an outpatient mental health private practice through the implementation of stress assessment via Depression, Anxiety, and Stress Scale 21. This is a comprehensive stress assessment project where the aim is to screen patient populations for specific stress levels and where respective psychotherapeutic stress reduction approaches will be used to minimize stress and enhance quality of life. In addressing this plan, an important approach is to incorporate the DASS21 scale into the basic assessment of patients as well as their follow-up visits to guarantee a systematic assessment of patients’ stress levels (D’Amico, et al., 2024). The shifts in the patient outcomes to be employed in the proposed project pertain to patients’ perceived stress levels, depression, and anxiety levels before and after the implementation of the stress assessment tool, in addition to patients’ satisfaction with the use of the stress assessment tool. The expected impact is expected to be the increased percentage of patients who will be relieved from stress, continued emotional well-being, and overall satisfaction with outpatient mental health services offered at the organization. |

    | |
    | — |
    | **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval**<br>Sources<br>Halford, W. K., & Frost, A. D. (2021). Depression anxiety stress scale-10: A brief measure for routine psychotherapy outcome and progress assessment. <br>_Behaviour Change_, <br>_38_(4), 221-234.<br>[https://www.cambridge.org/core/journals/behaviour-change/article/abs/depression-anxiety-stress-scale10-a-brief-measure-for-routine-psychotherapy-outcome-and-progress-assessment/2259B3A2EB360EE3BD007AAFCD73ED70](https://www.cambridge.org/core/journals/behaviour-change/article/abs/depression-anxiety-stress-scale10-a-brief-measure-for-routine-psychotherapy-outcome-and-progress-assessment/2259B3A2EB360EE3BD007AAFCD73ED70)<br>Ali, A. M., Hori, H., Kim, Y., & Kunugi, H. (2022). The Depression Anxiety Stress Scale 8-items expresses robust psychometric properties as an ideal shorter version of the Depression Anxiety Stress Scale 21 among healthy respondents from three continents. <br>_Frontiers in psychology_, <br>_13_, 799769. <br>[https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2022.799769/full](https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2022.799769/full)<br>![](https://www.sweetstudy.com/questions/rwh-blank)D’Amico, F., Navarrete, J., Montero-Marín, J., Cardeñosa-Valera, E., Navarro-Gil, M., Pérez-Aranda, A., … & Luciano, J. V. (2024). Cost-utility of attachment-based compassion therapy (ABCT) and mindfulness-based stress reduction (MBSR) in the management of depressive, anxious, and adjustment disorders in mental health settings: Economic evaluation alongside a randomized controlled trial. <br>_Mindfulness_, <br>_15_(3), 559-569. <br>[https://link.springer.com/article/10.1007/s12671-024-02319-4](https://link.springer.com/article/10.1007/s12671-024-02319-4) |

    | |
    | — |
    | **Data Security**<br>**Please provide a description of your data security plan for both physical and electronic data that**<br>**includes protected or identifying personal information. Include where the data will be stored, the**<br>**security of the location or computer system, the length of retention of the data, and the method**<br>**of disposition of old data.**<br>Regarding data protection, the necessary precautions shall be observed relating to paper documents that contain protected or identifying personal information as well as electronic records. Paper-based records will be secured in a locked cabinet or file, and digital records will be saved in password-protected computers only those persons have access who are concerned with it. This system will not be open to the public; access to all the departments will be allowed based on the access code and privileges granted to users. Secured updates or patches will be offered after each period to help in the protection of the system. Any accompanying physical documents will be secured in locked cabinets in an office only to be accessed by authorized personnel. Use of these cabinets will be limited and the keys shall be kept safely under lock and key by the authorized personnel.<br>As for the data retention period, the company will meet legal and industry standards concerning the data retention period with a concrete retention period defined in the data retention policy. The last point entails data disposal where the data is no longer useful or has aged out of the retention period set for it; it shall be deleted using standard methods of data disposal. Hard copy documents will be expelled using a cross-cut shredder for the destruction of any sensitive information. Digital data will be erased from the program by employing careful measures such as digital shredding and overwriting.<br>Additional daily, weekly, monthly, and annual checks are proposed to perform verification of the adherence to the data security requirements and to investigate possible threats. Specific personnel in each center will be tasked with conducting these audits from time to time and any issues arising out of this process will be addressed to minimize risks to the integrity of data. Finally, training in data security measures and guidelines will be provided to all employees to guard against violations of rules as well as to reduce cases of data leakage or instances in which unauthorized individuals gain access to such data. |
    | |

    **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project ApprovalStep 4: Acknowledgement of Responsibilities and Signatures**

    Please note that:

    · Any data collected from Herzing University students, alumni, faculty and/or staff and/or any other constituents for purposes of this project is proprietary. Any publication of findings may not identify or implicate Herzing University. Any external report produced on findings generated by this study, including any presentation or publication, may not identify, reference or implicate Herzing University in any way.

    · Upon completion of the project, a copy of the final deliverable will be submitted to Herzing University.

    · Any additional publications or presentations produced based upon this project will be submitted to Herzing University.

    I certify to the best of my knowledge the information presented is an accurate reflection of the proposed research project.

    ![](https://www.sweetstudy.com/questions/rwh-blank)Date: 6-9-24

    6

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    ## image2.jpg

    **FinalWrittenDeliverableTemplate3.2412.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/finalwrittendeliverabletemplate3-2412-docx-10183047)

    **Wilkerson1.23.25markup.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/wilkerson1-23-25markup-docx-10188125)

    **## FinalIRB.docx**

    ![](https://www.sweetstudy.com/questions/rwh-blank)

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    **Title: Implementing assessment tool which measures depression, anxiety and stress in a Outpatient Mental health Private Practice**

    **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval**

    Herzing University’s Institutional Review Board (IRB) reviews all student quality improvement or innovation project protocol requests to determine if it is human subject research that meets definitions in The Common Rule and therefore requires review and oversight by the IRB. It is the investigator’s responsibility to give complete information regarding the planned quality improvement processes. After submitting the application, the IRB will notify the applicant, in writing, of its decision or if additional information is needed.

    **Checklist**

    Please make sure to submit the following items along with this application for your submission:

    ☐ This application with signatures from you and your DNP Project Faculty

    ☐ A copy of all questionnaires and surveys, if used

    ☐ A copy of your CITI Certification (free certification for Herzing affiliates through Canvas)

    ☐ A copy of the application and approval letter from any external IRB (
    _if applicable_)

    ☐ Letter of approval from the Program Chair of the affiliated institution (
    _if applicable_)

    ![](https://www.sweetstudy.com/questions/rwh-blank)

    **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval**

    **Step 1: Your Information**

    | | |
    | — | — |
    | Project Title: | **Implementing assessment tool which measures depression, anxiety and stress in a Outpatient Mental health Private Practice** |
    | Doctorate Student Name: | Ramona Wilkerson |
    | Check One: | X Herzing University Student<br>☐ Student not affiliated with Herzing University – list institution this project is affiliated with: |
    | Email: | [rawilkerson@herzing.edu](mailto:rawilkerson@herzing.edu) |
    | Primary Phone Number: | 201-706-1511 |

    **Step 2: Location, Faculty, and Date Information**

    | | |
    | — | — |
    | Location/Sponsor: | Hudson Regional Hospital |
    | Faculty Information: | Faculty Name: Colleen Bartlett |
    | | Faculty Email:cbartlett@herzing.edu |
    | | Faculty Phone:<br>352-428-7472 |
    | Anticipated Start Date: | 2-1-24 |
    | Anticipated Completion Date: | 5-1-24 |

    **Step 3: Aim Statement Overview**

    **Aim Statement**

    | |
    | — |
    | Aim Statement<br>Key elements of the aim statement needed to be included:<br>1. What? What’s the problem or opportunity? 2. How much? By how much will you improve? Or<br>“how good” do you want to get? 3. By when? What is the date by which you will achieve the level of improvement you’ve set out to accomplish? 4. For whom? Who is the customer or population who will benefit from the improvement? 5. Where? What are the boundaries of the process or system you’re trying to improve? Where does it begin and end? |
    | Over the course of 8 weeks, this project will help to fill the gap which currently exists in the assessment of stress in outpatients in our clinic. Through administering the Depression, Anxiety, and Stress Scale (DASS21), we aim at conducting a more organized approach to evaluating stress prevalence in our patients (Ali, et al., 2022). Therefore, the aim will be to revolutionize patient care and satisfaction in routine practice through stress assessment, which, in turn, will enable proffering of appropriate psychotherapy stress remedies to patients. By week eight from the initiation of the project, we intend to review the patient outcomes as well as satisfaction rate and compare it with the initial parameters to note the impact of improvement. The direct target recipients of this improvement effort are the patient with mental illness that seek outpatient services from our practice. This project includes all facets of the stress assessment process, from incorporating stress assessment in to overall patient assessment, to providing adequate psychotherapy to stressed out patients, and ensuring the best quality of care for our patient panels (Halford, & Frost, 2021). |

    | |
    | — |
    | |

    **Instituti**

    | |
    | — |
    | **Project Overview**<br>Please provide a summary of the proposed quality improvement or innovation project including the purpose, proposed strategy to be utilized, proposed project measures that will be utilized to evaluate outcomes, and the anticipated/desired outcomes.<br>Overview of the problem <br>Stress as a concept is widely discussed and known to be the major factor affecting mental health globally. They are detrimental to the individual’s overall well-being and can lead to certain mental disorders like depression and anxiety disorders (WHO, 2022). Chronic stress worsens a patient’s symptoms in case of having some diagnosed psychiatric disorder, and acute stress may result in the creation of a new disorder if not addressed (American Psychiatry Association [APA], 2022).<br>Local Problem in Practice<br>Stress is an issue that is often present in the lives of many of the patients in our outpatient mental clinic, an independent Psychiatric practice. It has been seen that the patients used to complain and the doctors and other health care professionals who attended them also noticed that the various patients seemed highly stressed and anxious. Based on patient input records kept at the internal clinic, it is established that about 60% of patients show their stress levels ranging from moderate to severe during clinical evaluation and they have higher chances of being diagnosed with depression or anxiety disorders (Smith, 2023).<br>Purpose of the Project<br>The aim of this project is to pilot the use of the Depression, Anxiety, and Stress Scale (DASS21) and manage patient stress in a private practice outpatient mental health clinic. When implemented into practice, the project involves the identification and management of stress-illness, with the intention of optimizing the patient’s overall health outcomes about their mental health diagnoses.<br>Proposed Strategy<br>· Implementation of DASS21: Implement the DASS21 tool for the initial patient assessment and subsequent follow-up to quantify stress, anxiety, and depression scores.<br>· Training Staff: Trials and methods: Educate healthcare providers in the practice using the DASS21 in the administration and comprehension of results.<br>· Integration into Routine Care: Extend the use of DASS21 assessment to incorporate it into standard patient evaluations by using it at various patient encounters.<br>· Data Collection and Analysis: Quantitative patient data related to stress should be gathered before and after the use of DASS21. Age and other characteristics of the patients should also be described and compared between the two groups to determine if the intervention improved the outcomes of the patients.<br>Evaluative Measures<br>Pre- and Post-Implementation Stress Levels: Analyze the stress patient’s self-assessment using the scale before and after the application of the DASS21 tool.<br>Patient Satisfaction: Patient satisfaction can also be assessed through using surveys and feedback forms with the DASS21 patient’s tool (Beaufort, et al., 2017).<br>Clinical Outcomes: This will look at the degree of clinical improvement compared to baseline using medical documentation of patients’ status and follow-up surveys where the patients’ levels of depression and anxiety have presumably dropped.<br>Desired Outcomes<br>· Reduction in Stress Levels: Reduce the inhabitants’ reported tension points for patients to a very low level.<br>· Improved Mental Health: Improve general concern regarding possible depression and anxiety from stress management.<br>· Increased Patient Satisfaction: Improve the number of patients who are satisfied with the mental health services delivered by the organization.<br>· Enhanced Clinical Practice: Enhance patient care by adopting a validated instrument for stress evaluation as well as monitoring the effectiveness of clinical interventions for handling stress.<br>References <br>World Health Organization. (2022). World mental health report: Transforming mental health for all.<br>American Psychological Association. (2022). Stress in America. <br>[https://archive.hshsl.umaryland.edu/handle/10713/20295](https://archive.hshsl.umaryland.edu/handle/10713/20295)<br>Beaufort, I. N., De Weert-Van Oene, G. H., Buwalda, V. A., De Leeuw, J. R. J., & Goudriaan, A. E. (2017). The depression, anxiety and stress scale (DASS-21) as a screener for depression in substance use disorder inpatients: a pilot study. <br>_European addiction research_, <br>_23_(5), 260-268. <br>[https://karger.com/ear/article/23/5/260/119698/The-Depression-Anxiety-and-Stress-Scale-DASS-21-as](https://karger.com/ear/article/23/5/260/119698/The-Depression-Anxiety-and-Stress-Scale-DASS-21-as)<br>. |
    | **QI Framework**<br>Please provide an overview of the framework that will be utilized in the proposed project (e.g. KTA, PDSA, ADKAR, Lean, Six Sigma, DMAIC, etc.). |
    | The development of the suggested quality improvement plan is targeting the optimization of, and increasing patient satisfaction in an outpatient mental health private practice through the implementation of stress assessment via Depression, Anxiety, and Stress Scale 21. This is a comprehensive stress assessment project where the aim is to screen patient populations for specific stress levels and where respective psychotherapeutic stress reduction approaches will be used to minimize stress and enhance quality of life. In addressing this plan, an important approach is to incorporate the DASS21 scale into the basic assessment of patients as well as their follow-up visits to guarantee a systematic assessment of patients’ stress levels (D’Amico, et al., 2024). The shifts in the patient outcomes to be employed in the proposed project pertain to patients’ perceived stress levels, depression, and anxiety levels before and after the implementation of the stress assessment tool, in addition to patients’ satisfaction with the use of the stress assessment tool. The expected impact is expected to be the increased percentage of patients who will be relieved from stress, continued emotional well-being, and overall satisfaction with outpatient mental health services offered at the organization. |

    | |
    | — |
    | **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval**<br>Sources<br>Halford, W. K., & Frost, A. D. (2021). Depression anxiety stress scale-10: A brief measure for routine psychotherapy outcome and progress assessment. <br>_Behaviour Change_, <br>_38_(4), 221-234.<br>[https://www.cambridge.org/core/journals/behaviour-change/article/abs/depression-anxiety-stress-scale10-a-brief-measure-for-routine-psychotherapy-outcome-and-progress-assessment/2259B3A2EB360EE3BD007AAFCD73ED70](https://www.cambridge.org/core/journals/behaviour-change/article/abs/depression-anxiety-stress-scale10-a-brief-measure-for-routine-psychotherapy-outcome-and-progress-assessment/2259B3A2EB360EE3BD007AAFCD73ED70)<br>Ali, A. M., Hori, H., Kim, Y., & Kunugi, H. (2022). The Depression Anxiety Stress Scale 8-items expresses robust psychometric properties as an ideal shorter version of the Depression Anxiety Stress Scale 21 among healthy respondents from three continents. <br>_Frontiers in psychology_, <br>_13_, 799769. <br>[https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2022.799769/full](https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2022.799769/full)<br>![](https://www.sweetstudy.com/questions/rwh-blank)D’Amico, F., Navarrete, J., Montero-Marín, J., Cardeñosa-Valera, E., Navarro-Gil, M., Pérez-Aranda, A., … & Luciano, J. V. (2024). Cost-utility of attachment-based compassion therapy (ABCT) and mindfulness-based stress reduction (MBSR) in the management of depressive, anxious, and adjustment disorders in mental health settings: Economic evaluation alongside a randomized controlled trial. <br>_Mindfulness_, <br>_15_(3), 559-569. <br>[https://link.springer.com/article/10.1007/s12671-024-02319-4](https://link.springer.com/article/10.1007/s12671-024-02319-4) |

    | |
    | — |
    | **Data Security**<br>**Please provide a description of your data security plan for both physical and electronic data that**<br>**includes protected or identifying personal information. Include where the data will be stored, the**<br>**security of the location or computer system, the length of retention of the data, and the method**<br>**of disposition of old data.**<br>Regarding data protection, the necessary precautions shall be observed relating to paper documents that contain protected or identifying personal information as well as electronic records. Paper-based records will be secured in a locked cabinet or file, and digital records will be saved in password-protected computers only those persons have access who are concerned with it. This system will not be open to the public; access to all the departments will be allowed based on the access code and privileges granted to users. Secured updates or patches will be offered after each period to help in the protection of the system. Any accompanying physical documents will be secured in locked cabinets in an office only to be accessed by authorized personnel. Use of these cabinets will be limited and the keys shall be kept safely under lock and key by the authorized personnel.<br>As for the data retention period, the company will meet legal and industry standards concerning the data retention period with a concrete retention period defined in the data retention policy. The last point entails data disposal where the data is no longer useful or has aged out of the retention period set for it; it shall be deleted using standard methods of data disposal. Hard copy documents will be expelled using a cross-cut shredder for the destruction of any sensitive information. Digital data will be erased from the program by employing careful measures such as digital shredding and overwriting.<br>Additional daily, weekly, monthly, and annual checks are proposed to perform verification of the adherence to the data security requirements and to investigate possible threats. Specific personnel in each center will be tasked with conducting these audits from time to time and any issues arising out of this process will be addressed to minimize risks to the integrity of data. Finally, training in data security measures and guidelines will be provided to all employees to guard against violations of rules as well as to reduce cases of data leakage or instances in which unauthorized individuals gain access to such data. |
    | |

    **Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project ApprovalStep 4: Acknowledgement of Responsibilities and Signatures**

    Please note that:

    · Any data collected from Herzing University students, alumni, faculty and/or staff and/or any other constituents for purposes of this project is proprietary. Any publication of findings may not identify or implicate Herzing University. Any external report produced on findings generated by this study, including any presentation or publication, may not identify, reference or implicate Herzing University in any way.

    · Upon completion of the project, a copy of the final deliverable will be submitted to Herzing University.

    · Any additional publications or presentations produced based upon this project will be submitted to Herzing University.

    I certify to the best of my knowledge the information presented is an accurate reflection of the proposed research project.

    ![](https://www.sweetstudy.com/questions/rwh-blank)Date: 6-9-24

    6

    7

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    ## image1.jpg

    ## image2.jpeg

    ## image2.jpg

    **FinalWrittenDeliverableTemplate3.2412.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/finalwrittendeliverabletemplate3-2412-docx-10183047)

    **Wilkerson1.23.25markup.docx**

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  • [Solved] Revisit the goals and objectives from your Practicum Experience Plan. Explain the degree to which you achieved each during the practicum experience.

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  • [Solved] Reflections on Evidence-Based Practice, Clinical Practice Guidelines, and Standards of Care

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    see instructions attached. Assignemnt is based on Psychiatric Nurse practictioner roations. – 2 years ago **files (1)** – ## Weekn10instructionds.docx **## Weekn10instructionds.docx** To Prepare · Identify a Case: · Choose/Create a patient case from your clinical experience where you and your precep…

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    see instructions attached.

    Assignemnt is  based on Psychiatric Nurse practictioner roations.

    – 2 years ago

    **files (1)**

    – ## Weekn10instructionds.docx

    **## Weekn10instructionds.docx**

    To Prepare

    · Identify a Case:

    · Choose/Create a patient case from your clinical experience where you and your preceptor approached the treatment plan differently.

    · Research evidence-based information pertinent to your chosen patient for treatment Clinical Practice Guidelines and Standards of Care.

    **Submission Requirements:**

    · Length: 3-4 pages, double-spaced, APA format.

    · Cite at least 3 peer-reviewed sources to support your analysis.

    **Evaluation Criteria:**

    · Clarity and completeness of the case summary.

    · Depth of analysis and comparison between treatment plans.

    · Use of evidence-based rationale for your alternative plan.

    · Reflection on learning and future application.

    · Proper use of APA formatting and references.

    Assignment

    Write a paper:

    **Briefly summarize:**

    · The patient case, including all relevant information: the patient's history, assessment findings, medications, any pertinent testing, presenting symptoms, and the final diagnosis (ensure patient confidentiality).

    **Compare Treatment Plans:**

    · Describe your preceptor’s recommended treatment plan and interventions.

    · Explain the alternative treatment plan you would have recommended as a nurse practitioner based upon Clinical Practice Guidelines and Standards of Care.

    **Justify Your Approach:**

    · Use evidence-based guidelines, clinical research, and relevant literature to support your alternative plan.

    · Discuss why you believe your approach would be effective, considering the patient’s history, condition, and individual needs.
    Reflect on Differences:

    · Analyze the differences between your plan and your preceptor’s.

    · Consider factors such as clinical experience, knowledge, patient-centered care, and the influence of evidence-based practice in decision-making.

    Lessons Learned:

    · Reflect on how this experience has influenced your clinical practice and approach to treatment planning.

    · Discuss how you can apply what you learned to future patient care.

    · How might you approach another provider professionally in the future when you find treatment plans differing during collaboration on the patient case?

    **## Weekn10instructionds.docx**

    To Prepare

    · Identify a Case:

    · Choose/Create a patient case from your clinical experience where you and your preceptor approached the treatment plan differently.

    · Research evidence-based information pertinent to your chosen patient for treatment Clinical Practice Guidelines and Standards of Care.

    **Submission Requirements:**

    · Length: 3-4 pages, double-spaced, APA format.

    · Cite at least 3 peer-reviewed sources to support your analysis.

    **Evaluation Criteria:**

    · Clarity and completeness of the case summary.

    · Depth of analysis and comparison between treatment plans.

    · Use of evidence-based rationale for your alternative plan.

    · Reflection on learning and future application.

    · Proper use of APA formatting and references.

    Assignment

    Write a paper:

    **Briefly summarize:**

    · The patient case, including all relevant information: the patient's history, assessment findings, medications, any pertinent testing, presenting symptoms, and the final diagnosis (ensure patient confidentiality).

    **Compare Treatment Plans:**

    · Describe your preceptor’s recommended treatment plan and interventions.

    · Explain the alternative treatment plan you would have recommended as a nurse practitioner based upon Clinical Practice Guidelines and Standards of Care.

    **Justify Your Approach:**

    · Use evidence-based guidelines, clinical research, and relevant literature to support your alternative plan.

    · Discuss why you believe your approach would be effective, considering the patient’s history, condition, and individual needs.
    Reflect on Differences:

    · Analyze the differences between your plan and your preceptor’s.

    · Consider factors such as clinical experience, knowledge, patient-centered care, and the influence of evidence-based practice in decision-making.

    Lessons Learned:

    · Reflect on how this experience has influenced your clinical practice and approach to treatment planning.

    · Discuss how you can apply what you learned to future patient care.

    · How might you approach another provider professionally in the future when you find treatment plans differing during collaboration on the patient case?

  • [Solved] Nursing report 4 pages

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  • [Solved] Nursing BYR-ASSIGNMENT

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    PLEASE SEE THE ATTACHED DOCUMENT FOR INSTRUCTIONS AND RUBRIC EACH INSTRUCTION MUST BE FOLLOWED AS INDICATED NO MORE THAN 10% PLAGIO ALLOWED CHECK YOUR SPELLING AND GRAMMAR IN THE SLIDES AND SPEAKER NOTES SLIDES MUST BE CONDENSED NEED HAVE PROPER INFORMATION , NOT ALLOWED WITH FEW SENTENCES 14 SLIDES…

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    PLEASE SEE THE ATTACHED DOCUMENT FOR INSTRUCTIONS AND RUBRIC

    EACH INSTRUCTION MUST BE FOLLOWED AS INDICATED

    NO MORE THAN 10% PLAGIO ALLOWED

    CHECK YOUR SPELLING AND GRAMMAR IN THE SLIDES AND SPEAKER NOTES

    SLIDES MUST BE CONDENSED NEED HAVE PROPER INFORMATION , NOT ALLOWED WITH FEW SENTENCES

    14 SLIDES

    DUE DATE JANUARY 29, 2025

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    INSTRUCTIONSANDRUBRIC.docx](https://www.sweetstudy.com/files/instructionsandrubric-docx-10169937 "INSTRUCTIONSANDRUBRIC.docx")

    – 2 years ago

  • [Solved] NUR502 week 3

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  • [Solved] SOAP Note 2 Comprehensive SOAP Cardio/Respiratory

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    – 2 years ago **files (4)** – ## SOAPNote2ComprehensiveSOAPCardioRespiratory.docx – ## EvaluationandManagementEMScoreSheet8985-2-1.pdf – GroupSOAPRubricandTemplate.docx – ComprehensiveSOAPNoteExample.doc2.pdf **## SOAPNote2ComprehensiveSOAPCardioRespiratory.docx** **Please follow APA format, add cit…

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    **## SOAPNote2ComprehensiveSOAPCardioRespiratory.docx**

    **Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**

    **Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.**

    ·
    **Upload a copy of your completed SOAP note.**

    ·
    **Upload a copy of the evaluation & management score sheet.**

    **Case Study:** A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.

    **## EvaluationandManagementEMScoreSheet8985-2-1.pdf**

    E/M Documentation Auditor’s Instructions

    1. History
    Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
    best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
    identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
    of history.

    After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.

    HPI: Status of chronic conditions:
    q 1 condition q 2 conditions q 3 conditions

    q
    Status of
    1-2 chronic

    Status of 3
    chronic

    conditions conditionsOR

    HPI (history of present illness) elements:
    q Location q Severity q Timing q Modifying factors

    q Quality q Duration q Context q Associated signs and symptoms

    q
    Brief
    (1-3)

    Extended
    (4 or more)

    ROS (review of systems):

    q Constitutional q Ears,nose, q GI q Integumentaryq Endo
    (wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph

    q Eyes q Card/vasc q Musculo q Neuro q All/immuno
    q Resp q Psych q All others negative

    q
    None

    q
    Pertinent to
    problem

    (1 system)

    q

    Extended
    (2-9 systems)

    *Complete

    PFSH (past medical, family, social history) areas:
    q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
    q Family history (a review of medical events in the patient's family, including diseases which may be

    hereditary or place the patient at risk)
    q Social history (an age appropriate review of past and current activities)

    plete ROS: 10 or more systems or the pertinent positives and/or negatives of

    q
    None

    q
    Pertinent

    (1 history area)
    e**Complet
    y(2 or 3 histor

    areas)

    PROBLEM
    FOCUSED

    EXP.PROB.
    FOCUSED DETAILED -COMPRE

    HENSIVE

    q

    T
    O

    R
    Y

    I
    S

    H

    *Com
    some systems with a statement “all others negative”.

    **Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.

    3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
    c) Initial Hospital Observation; d) Initial Nursing Facility Care.

    NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
    information about the PFSH. Please refer to procedure code descriptions.

    2. Examination

    Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
    Circle the type of examination within the appropriate grid in Section 5.

    Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM

    Affected body area or organ system and other symptomatic or related organ system(s)
    (additional systems up to total of 7)

    EXPANDED PROBLEM
    FOCUSED EXAM

    Extended exam of affected area(s) and other symptomatic or related organ system(s)
    (additional systems up to total of 7 or more depth than above) DETAILED EXAM

    General multi-system exam (8 or more systems) or complete exam of a single organ system
    (complete single exam not defined in these instructions) COMPREHENSIVE EXAM

    A
    M

    E
    X

    Body areas:
    q Head, including face q Chest, including breasts and axillae
    q Back, including spine qGenitalia, groin, buttocks

    Organ systems:

    q

    q

    Abdomen q Neck
    Each extremity

    q q q
    1 body
    area or
    system

    Up to 7
    systems

    Up to 7 8 or more
    systems systems

    q Constitutional q Ears,nose, q Resp q Musculo q Psych
    ) (e.g., vitals, gen app mouth, throat q GI q Skin

    q Eyes q Cardiovascular q GU q Neuro
    q Hem/lymph/imm

    PROBLEM
    FOCUSED

    EXP.PROB.
    FOCUSED DETAILED COMPRE-

    HENSIVE

    q

    – 1 –

    q

    q

    q

    3. Medical Decision Making

    Number of Diagnoses or Treatment Options

    Identify each problem or treatment option mentioned in the record.
    Enter the number in each of the categories in Column B in the table
    below. (There are maximum number in two categories.)

    Number of Diagnoses or Treatment Options
    A B X C = D

    Problem(s) Status Number Points Result

    Self-limited or minor
    (stable, improved or worsening) Max = 2 1
    Est. problem (to examiner); stable, improved 1

    Est. problem (to examiner); worsening 2

    New problem (to examiner); no additional
    workup planned

    Max = 1

    3

    New prob. (to examiner); add. workup planned 4

    TOTAL
    Multiply the number in columns B & C and put the product in column D.
    Enter a total for column D.

    Bring total to line A in Final Result for Complexity (table below)

    Amount and/or Complexity of Data Reviewed

    For each category of reviewed data identified, circle the number in the points
    column. Total the points.

    Amount and/or Complexity of Data Reviewed
    Reviewed Data Points

    1

    1

    1

    1

    1

    2

    2

    Review and/or order of clinical lab tests

    Review and/or order of tests in the radiology section of CPT

    Review and/or order of tests in the medicine section of CPT

    Discussion of test results with performing physician

    Decision to obtain old records and/or obtain history from
    someone other than patient

    Review and summarization of old records and/or obtaining
    history from someone other than patient and/or discussion of
    case with another health care provider

    Independent visualization of image, tracing or specimen itself
    (not simply review of report)

    TOTAL
    Bring total to line C in Final Result for Complexity (table below)

    Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
    contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
    most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
    Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality

    Level of
    Risk

    Presenting Problem(s) Diagnostic Procedure(s)
    Ordered

    Management Options
    Selected

    Minimal
    • One self-limited or minor problem,

    e.g., cold, insect bite, tinea corporis

    • Laboratory tests requiring venipuncture
    • Chest x-rays
    • EKG/EEG
    • Urinalysis
    • Ultrasound, e.g., echo
    • KOH prep

    • Rest
    • Gargles
    • Elastic bandages
    • Superficial dressings

    Low

    • Two or more self-limited or minor problems
    • One stable chronic illness, e.g., well controlled

    hypertension or non-insulin dependent diabetes,
    cataract, BPH

    • Acute uncomplicated illness or injury, e.g., cystitis, allergic
    rhinitis, simple sprain

    • Physiologic tests not under stress, e.g.,pulmonary
    function tests

    • Non-cardiovascular imaging studies with contrast,
    e.g., barium enema

    • Superficial needle biopsies
    • Clincal laboratory tests requiring arterial puncture
    • Skin biopsies

    • Over-the-counter drugs
    • Minor surgery with no identified risk factors
    • Physical therapy
    • Occupational therapy
    • IV fluids without additives

    Moderate

    • One or more chronic illnesses with mild exacerbation,
    progression, or side effects of treatment

    • Two or more stable chronic illnesses
    • Undiagnosed new problem with uncertain prognosis,
    e.g., lump in breast

    • Acute illness with systemic symptoms, e.g.,
    pyelonephritis, pneumonitis, colitis

    • Acute complicated injury, e.g., head injury with brief loss
    of consciousness

    • Physiologic tests under stress, e.g., cardiac stress test,
    fetal contraction stress test

    • Diagnostic endoscopies with no identified risk factors
    • Deep needle or incisional biopsy
    • Cardiovascular imaging studies with contrast and no

    identified risk factors, e.g., arteriogram cardiac cath
    • Obtain fluid from body cavity, e.g., lumbar puncture,

    thoracentesis, culdocentesis

    • Minor surgery with identified risk factors
    • Elective major surgery (open, percutaneous or

    endoscopic) with no identified risk factors
    • Prescription drug management
    • Therapeutic nuclear medicine
    • IV fluids with addititives
    • Closed treatment of fracture or dislocation without

    manipulation

    High

    • One or more chronic illnesses with severe exacerbation,
    progression, or side effects of treatment

    • Acute or chronic illnesses or injuries that may pose a threat to
    life or bodily function, e.g., multiple trauma, acute MI,
    pulmonary embolus, severe respiratory distress, progressive
    severe rheumatoid arthritis, psychiatric illness with potential
    threat to self or others, peritonitis, acute renal failure

    • An abrupt change in neurologic status, e.g., seizure, TIA,
    weakness or sensory loss

    • Cardiovascular imaging studies with contrast with
    identified risk factors

    • Cardiac electrophysiological tests
    • Diagnostic endoscopies with identified risk factors
    • Discography

    • Elective major surgery (open, percutaneous or
    endoscopic with identified risk factors)

    • Emergency major surgery (open, percutaneous or
    endoscopic)

    • Parenteral controlled substances
    • Drug therapy requiring intensive monitoring for toxicity
    • Decision not to resuscitate or to de-escalate care

    because of poor prognosis

    Final Result for Complexity
    Draw a line down any column with 2 or 3 circles to identify the type of decision making in
    that column. Otherwise, draw a line down the column with the 2nd circle from the left.
    After completing this table, which classifies complexity, circle the type of decision
    making within the appropriate grid in Section 5.

    Final Result for Complexity

    A Number diagnoses or
    treatment options

    ≤ 1
    Minimal

    2
    Limited

    3
    Multiple

    ≥ 4
    Extensive

    B Highest Risk Minimal Low Moderate High

    C Amount and complexity
    of data

    ≤ 1
    Minimal
    or low

    2
    Limited

    3
    Multiple

    ≥ 4
    Extensive

    Type of decision making STRAIGHT-
    FORWARD

    LOW
    COMPLEX.

    MODERATE
    COMPLEX.

    HIGH
    COMPLEX.

    4. Time

    If the physician documents total time and suggests that counseling or coordinating care dominates
    (more than 50%) the encounter, time may determine level of service. Documentation may refer to:
    prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk
    reduction or discussion with another health care provider.

    Face-to-face in outpatient setting
    Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No

    Does documentation describe the content of counseling or coordinating care? Yes No

    Does documentation reveal that more than half of the time was counseling or
    coordinating care? Yes No

    If all answers are "yes", select level based on time.

    – 2 –

    M
    E
    D
    I
    C
    A
    L

    D
    E
    C
    I
    S
    I
    O

    N

    M

    A
    K
    I
    N
    G

    5. L E V E L O F S E R V I C E

    New Office, Outpatient and Emergency Room
    New Office / Outpatient / ER Established Office / Outpatient
    Requires 3 components within shaded area Requires 2 components within shaded area

    History
    PF

    ER: PF
    EPF

    ER: EPF
    D

    ER: EPF
    C

    ER: D
    C

    ER: C Minimal
    problem
    that may
    not
    require
    presence
    of
    physician

    PF EPF D C

    Examination
    PF

    ER: PF

    EPF

    ER: EPF

    D

    ER: EPF

    C

    ER: D

    C

    ER: C
    PF EPF D C

    Complexity
    of medical
    decision

    SF
    ER: SF

    SF
    ER: L

    L
    ER: M

    M
    ER: M

    H
    ER: H SF L M H

    Average time
    (minutes)

    ER has no average
    time

    10 New (99201)

    ER (99281)

    20 New (99202)

    ER (99282)

    30 New (99203)

    ER (99283)

    45 New (99204)

    ER (99284)

    60 New (99205)

    ER (99285)

    5
    (99211)

    10
    (99212)

    15
    (99213)

    25
    (99214)

    40
    (99215)

    Level I II III IV V I II III IV V

    Hospital Care Initial Hospital/Observation Subsequent Hospital/Observation
    Requires 3 components within shaded area Requires 2 components within shaded area

    History D/C C C PF interval EPF interval D interval

    Examination D/C C C PF EPF D
    Complexity of medical

    decision SF/L M H SF/L M H

    Average time (minutes)
    30 Init hosp (99221)
    30 Init observ Care

    (99218)

    50 Init hosp (99222)
    50 Init observ Care

    (99219)

    70 Init hosp (99223)
    70 Init observ Care

    (99220)

    15 Sub hosp (99231)
    15 Sub observ care

    (99224)

    25 Sub hosp (99232)
    25 Sub observ care

    (99225)

    35 Sub hosp (99233)
    35 Sub observ care

    (99226)

    Level I II III I II III

    Nursing Facility
    Care Initial Nursing Facility

    Requires 3 components within shaded area
    Subsequent Nursing Facility
    Requires 2 components within shaded area

    Other Nursing Facility
    (Annual Assessment)

    Requires 3 components within shaded area

    History D/C C C PF interval EPF interval D interval C interval D interval

    Examination D/C C C PF EPF D C C

    Complexity of medical
    decision SF/L M H SF L M H L/M

    Average time (minutes) 25
    99304

    35
    99305

    45
    99306

    10
    99307

    15
    99308

    25
    99309

    35
    99310

    30
    99318

    Level I II III I II III IV

    Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care

    Requires 3 components within shaded area Requires 2 onents within shaded area

    History PF EPF D C C PF interval EPF interval D interval C interval

    Examination PF EPF D C C PF EPF D C
    Complexity of

    medical decision SF L M M H SF L M M/H
    Average time
    (minutes)

    20
    Domiciliary (99324)
    Home care (99341)

    30
    Domiciliary (99325)
    Home care (99342)

    45
    Domiciliary (99326)
    Home care (99343)

    60
    Domiciliary (99327)
    Home care (99344)

    75
    Domiciliary (99328)
    Home care (99345)

    15
    Domiciliary (99334)
    Home care (99347)

    25
    Domiciliary (99335)
    Home care (99348)

    40
    Domiciliary (99336)
    Home care (99349)

    60
    Domiciliary (99337)
    Home care (99350)

    Level I II III IV V I II III IV
    PF = Problem focused EPF = Expanded problem focused D = Detailed C = Comprehensive SF = Straightforward L = Low M = Moderate H = High

    – 3 –

    Establishe
    dcomp

    New

    – Novitas Solutions Documentation Worksheet
    – History Section
    – Examination Section
    – Medical Decision Making Section
    – Time Section
    – Level of Service Grids

    **GroupSOAPRubricandTemplate.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/groupsoaprubricandtemplate-docx-10170163)

    **ComprehensiveSOAPNoteExample.doc2.pdf**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/comprehensivesoapnoteexample-doc2-pdf-10170161)

    **ComprehensiveSOAPNoteExample.doc2.pdf**

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    **## SOAPNote2ComprehensiveSOAPCardioRespiratory.docx**

    **Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**

    **Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.**

    ·
    **Upload a copy of your completed SOAP note.**

    ·
    **Upload a copy of the evaluation & management score sheet.**

    **Case Study:** A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.

    **## EvaluationandManagementEMScoreSheet8985-2-1.pdf**

    E/M Documentation Auditor’s Instructions

    1. History
    Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
    best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
    identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
    of history.

    After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.

    HPI: Status of chronic conditions:
    q 1 condition q 2 conditions q 3 conditions

    q
    Status of
    1-2 chronic

    Status of 3
    chronic

    conditions conditionsOR

    HPI (history of present illness) elements:
    q Location q Severity q Timing q Modifying factors

    q Quality q Duration q Context q Associated signs and symptoms

    q
    Brief
    (1-3)

    Extended
    (4 or more)

    ROS (review of systems):

    q Constitutional q Ears,nose, q GI q Integumentaryq Endo
    (wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph

    q Eyes q Card/vasc q Musculo q Neuro q All/immuno
    q Resp q Psych q All others negative

    q
    None

    q
    Pertinent to
    problem

    (1 system)

    q

    Extended
    (2-9 systems)

    *Complete

    PFSH (past medical, family, social history) areas:
    q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
    q Family history (a review of medical events in the patient's family, including diseases which may be

    hereditary or place the patient at risk)
    q Social history (an age appropriate review of past and current activities)

    plete ROS: 10 or more systems or the pertinent positives and/or negatives of

    q
    None

    q
    Pertinent

    (1 history area)
    e**Complet
    y(2 or 3 histor

    areas)

    PROBLEM
    FOCUSED

    EXP.PROB.
    FOCUSED DETAILED -COMPRE

    HENSIVE

    q

    T
    O

    R
    Y

    I
    S

    H

    *Com
    some systems with a statement “all others negative”.

    **Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.

    3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
    c) Initial Hospital Observation; d) Initial Nursing Facility Care.

    NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
    information about the PFSH. Please refer to procedure code descriptions.

    2. Examination

    Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
    Circle the type of examination within the appropriate grid in Section 5.

    Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM

    Affected body area or organ system and other symptomatic or related organ system(s)
    (additional systems up to total of 7)

    EXPANDED PROBLEM
    FOCUSED EXAM

    Extended exam of affected area(s) and other symptomatic or related organ system(s)
    (additional systems up to total of 7 or more depth than above) DETAILED EXAM

    General multi-system exam (8 or more systems) or complete exam of a single organ system
    (complete single exam not defined in these instructions) COMPREHENSIVE EXAM

    A
    M

    E
    X

    Body areas:
    q Head, including face q Chest, including breasts and axillae
    q Back, including spine qGenitalia, groin, buttocks

    Organ systems:

    q

    q

    Abdomen q Neck
    Each extremity

    q q q
    1 body
    area or
    system

    Up to 7
    systems

    Up to 7 8 or more
    systems systems

    q Constitutional q Ears,nose, q Resp q Musculo q Psych
    ) (e.g., vitals, gen app mouth, throat q GI q Skin

    q Eyes q Cardiovascular q GU q Neuro
    q Hem/lymph/imm

    PROBLEM
    FOCUSED

    EXP.PROB.
    FOCUSED DETAILED COMPRE-

    HENSIVE

    q

    – 1 –

    q

    q

    q

    3. Medical Decision Making

    Number of Diagnoses or Treatment Options

    Identify each problem or treatment option mentioned in the record.
    Enter the number in each of the categories in Column B in the table
    below. (There are maximum number in two categories.)

    Number of Diagnoses or Treatment Options
    A B X C = D

    Problem(s) Status Number Points Result

    Self-limited or minor
    (stable, improved or worsening) Max = 2 1
    Est. problem (to examiner); stable, improved 1

    Est. problem (to examiner); worsening 2

    New problem (to examiner); no additional
    workup planned

    Max = 1

    3

    New prob. (to examiner); add. workup planned 4

    TOTAL
    Multiply the number in columns B & C and put the product in column D.
    Enter a total for column D.

    Bring total to line A in Final Result for Complexity (table below)

    Amount and/or Complexity of Data Reviewed

    For each category of reviewed data identified, circle the number in the points
    column. Total the points.

    Amount and/or Complexity of Data Reviewed
    Reviewed Data Points

    1

    1

    1

    1

    1

    2

    2

    Review and/or order of clinical lab tests

    Review and/or order of tests in the radiology section of CPT

    Review and/or order of tests in the medicine section of CPT

    Discussion of test results with performing physician

    Decision to obtain old records and/or obtain history from
    someone other than patient

    Review and summarization of old records and/or obtaining
    history from someone other than patient and/or discussion of
    case with another health care provider

    Independent visualization of image, tracing or specimen itself
    (not simply review of report)

    TOTAL
    Bring total to line C in Final Result for Complexity (table below)

    Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
    contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
    most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
    Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality

    Level of
    Risk

    Presenting Problem(s) Diagnostic Procedure(s)
    Ordered

    Management Options
    Selected

    Minimal
    • One self-limited or minor problem,

    e.g., cold, insect bite, tinea corporis

    • Laboratory tests requiring venipuncture
    • Chest x-rays
    • EKG/EEG
    • Urinalysis
    • Ultrasound, e.g., echo
    • KOH prep

    • Rest
    • Gargles
    • Elastic bandages
    • Superficial dressings

    Low

    • Two or more self-limited or minor problems
    • One stable chronic illness, e.g., well controlled

    hypertension or non-insulin dependent diabetes,
    cataract, BPH

    • Acute uncomplicated illness or injury, e.g., cystitis, allergic
    rhinitis, simple sprain

    • Physiologic tests not under stress, e.g.,pulmonary
    function tests

    • Non-cardiovascular imaging studies with contrast,
    e.g., barium enema

    • Superficial needle biopsies
    • Clincal laboratory tests requiring arterial puncture
    • Skin biopsies

    • Over-the-counter drugs
    • Minor surgery with no identified risk factors
    • Physical therapy
    • Occupational therapy
    • IV fluids without additives

    Moderate

    • One or more chronic illnesses with mild exacerbation,
    progression, or side effects of treatment

    • Two or more stable chronic illnesses
    • Undiagnosed new problem with uncertain prognosis,
    e.g., lump in breast

    • Acute illness with systemic symptoms, e.g.,
    pyelonephritis, pneumonitis, colitis

    • Acute complicated injury, e.g., head injury with brief loss
    of consciousness

    • Physiologic tests under stress, e.g., cardiac stress test,
    fetal contraction stress test

    • Diagnostic endoscopies with no identified risk factors
    • Deep needle or incisional biopsy
    • Cardiovascular imaging studies with contrast and no

    identified risk factors, e.g., arteriogram cardiac cath
    • Obtain fluid from body cavity, e.g., lumbar puncture,

    thoracentesis, culdocentesis

    • Minor surgery with identified risk factors
    • Elective major surgery (open, percutaneous or

    endoscopic) with no identified risk factors
    • Prescription drug management
    • Therapeutic nuclear medicine
    • IV fluids with addititives
    • Closed treatment of fracture or dislocation without

    manipulation

    High

    • One or more chronic illnesses with severe exacerbation,
    progression, or side effects of treatment

    • Acute or chronic illnesses or injuries that may pose a threat to
    life or bodily function, e.g., multiple trauma, acute MI,
    pulmonary embolus, severe respiratory distress, progressive
    severe rheumatoid arthritis, psychiatric illness with potential
    threat to self or others, peritonitis, acute renal failure

    • An abrupt change in neurologic status, e.g., seizure, TIA,
    weakness or sensory loss

    • Cardiovascular imaging studies with contrast with
    identified risk factors

    • Cardiac electrophysiological tests
    • Diagnostic endoscopies with identified risk factors
    • Discography

    • Elective major surgery (open, percutaneous or
    endoscopic with identified risk factors)

    • Emergency major surgery (open, percutaneous or
    endoscopic)

    • Parenteral controlled substances
    • Drug therapy requiring intensive monitoring for toxicity
    • Decision not to resuscitate or to de-escalate care

    because of poor prognosis

    Final Result for Complexity
    Draw a line down any column with 2 or 3 circles to identify the type of decision making in
    that column. Otherwise, draw a line down the column with the 2nd circle from the left.
    After completing this table, which classifies complexity, circle the type of decision
    making within the appropriate grid in Section 5.

    Final Result for Complexity

    A Number diagnoses or
    treatment options

    ≤ 1
    Minimal

    2
    Limited

    3
    Multiple

    ≥ 4
    Extensive

    B Highest Risk Minimal Low Moderate High

    C Amount and complexity
    of data

    ≤ 1
    Minimal
    or low

    2
    Limited

    3
    Multiple

    ≥ 4
    Extensive

    Type of decision making STRAIGHT-
    FORWARD

    LOW
    COMPLEX.

    MODERATE
    COMPLEX.

    HIGH
    COMPLEX.

    4. Time

    If the physician documents total time and suggests that counseling or coordinating care dominates
    (more than 50%) the encounter, time may determine level of service. Documentation may refer to:
    prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk
    reduction or discussion with another health care provider.

    Face-to-face in outpatient setting
    Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No

    Does documentation describe the content of counseling or coordinating care? Yes No

    Does documentation reveal that more than half of the time was counseling or
    coordinating care? Yes No

    If all answers are "yes", select level based on time.

    – 2 –

    M
    E
    D
    I
    C
    A
    L

    D
    E
    C
    I
    S
    I
    O

    N

    M

    A
    K
    I
    N
    G

    5. L E V E L O F S E R V I C E

    New Office, Outpatient and Emergency Room
    New Office / Outpatient / ER Established Office / Outpatient
    Requires 3 components within shaded area Requires 2 components within shaded area

    History
    PF

    ER: PF
    EPF

    ER: EPF
    D

    ER: EPF
    C

    ER: D
    C

    ER: C Minimal
    problem
    that may
    not
    require
    presence
    of
    physician

    PF EPF D C

    Examination
    PF

    ER: PF

    EPF

    ER: EPF

    D

    ER: EPF

    C

    ER: D

    C

    ER: C
    PF EPF D C

    Complexity
    of medical
    decision

    SF
    ER: SF

    SF
    ER: L

    L
    ER: M

    M
    ER: M

    H
    ER: H SF L M H

    Average time
    (minutes)

    ER has no average
    time

    10 New (99201)

    ER (99281)

    20 New (99202)

    ER (99282)

    30 New (99203)

    ER (99283)

    45 New (99204)

    ER (99284)

    60 New (99205)

    ER (99285)

    5
    (99211)

    10
    (99212)

    15
    (99213)

    25
    (99214)

    40
    (99215)

    Level I II III IV V I II III IV V

    Hospital Care Initial Hospital/Observation Subsequent Hospital/Observation
    Requires 3 components within shaded area Requires 2 components within shaded area

    History D/C C C PF interval EPF interval D interval

    Examination D/C C C PF EPF D
    Complexity of medical

    decision SF/L M H SF/L M H

    Average time (minutes)
    30 Init hosp (99221)
    30 Init observ Care

    (99218)

    50 Init hosp (99222)
    50 Init observ Care

    (99219)

    70 Init hosp (99223)
    70 Init observ Care

    (99220)

    15 Sub hosp (99231)
    15 Sub observ care

    (99224)

    25 Sub hosp (99232)
    25 Sub observ care

    (99225)

    35 Sub hosp (99233)
    35 Sub observ care

    (99226)

    Level I II III I II III

    Nursing Facility
    Care Initial Nursing Facility

    Requires 3 components within shaded area
    Subsequent Nursing Facility
    Requires 2 components within shaded area

    Other Nursing Facility
    (Annual Assessment)

    Requires 3 components within shaded area

    History D/C C C PF interval EPF interval D interval C interval D interval

    Examination D/C C C PF EPF D C C

    Complexity of medical
    decision SF/L M H SF L M H L/M

    Average time (minutes) 25
    99304

    35
    99305

    45
    99306

    10
    99307

    15
    99308

    25
    99309

    35
    99310

    30
    99318

    Level I II III I II III IV

    Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care

    Requires 3 components within shaded area Requires 2 onents within shaded area

    History PF EPF D C C PF interval EPF interval D interval C interval

    Examination PF EPF D C C PF EPF D C
    Complexity of

    medical decision SF L M M H SF L M M/H
    Average time
    (minutes)

    20
    Domiciliary (99324)
    Home care (99341)

    30
    Domiciliary (99325)
    Home care (99342)

    45
    Domiciliary (99326)
    Home care (99343)

    60
    Domiciliary (99327)
    Home care (99344)

    75
    Domiciliary (99328)
    Home care (99345)

    15
    Domiciliary (99334)
    Home care (99347)

    25
    Domiciliary (99335)
    Home care (99348)

    40
    Domiciliary (99336)
    Home care (99349)

    60
    Domiciliary (99337)
    Home care (99350)

    Level I II III IV V I II III IV
    PF = Problem focused EPF = Expanded problem focused D = Detailed C = Comprehensive SF = Straightforward L = Low M = Moderate H = High

    – 3 –

    Establishe
    dcomp

    New

    – Novitas Solutions Documentation Worksheet
    – History Section
    – Examination Section
    – Medical Decision Making Section
    – Time Section
    – Level of Service Grids

    **GroupSOAPRubricandTemplate.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/groupsoaprubricandtemplate-docx-10170163)

    **ComprehensiveSOAPNoteExample.doc2.pdf**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/comprehensivesoapnoteexample-doc2-pdf-10170161)

    **## SOAPNote2ComprehensiveSOAPCardioRespiratory.docx**

    **Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**

    **Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.**

    ·
    **Upload a copy of your completed SOAP note.**

    ·
    **Upload a copy of the evaluation & management score sheet.**

    **Case Study:** A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.

    **## EvaluationandManagementEMScoreSheet8985-2-1.pdf**

    E/M Documentation Auditor’s Instructions

    1. History
    Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
    best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
    identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
    of history.

    After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.

    HPI: Status of chronic conditions:
    q 1 condition q 2 conditions q 3 conditions

    q
    Status of
    1-2 chronic

    Status of 3
    chronic

    conditions conditionsOR

    HPI (history of present illness) elements:
    q Location q Severity q Timing q Modifying factors

    q Quality q Duration q Context q Associated signs and symptoms

    q
    Brief
    (1-3)

    Extended
    (4 or more)

    ROS (review of systems):

    q Constitutional q Ears,nose, q GI q Integumentaryq Endo
    (wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph

    q Eyes q Card/vasc q Musculo q Neuro q All/immuno
    q Resp q Psych q All others negative

    q
    None

    q
    Pertinent to
    problem

    (1 system)

    q

    Extended
    (2-9 systems)

    *Complete

    PFSH (past medical, family, social history) areas:
    q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
    q Family history (a review of medical events in the patient's family, including diseases which may be

    hereditary or place the patient at risk)
    q Social history (an age appropriate review of past and current activities)

    plete ROS: 10 or more systems or the pertinent positives and/or negatives of

    q
    None

    q
    Pertinent

    (1 history area)
    e**Complet
    y(2 or 3 histor

    areas)

    PROBLEM
    FOCUSED

    EXP.PROB.
    FOCUSED DETAILED -COMPRE

    HENSIVE

    q

    T
    O

    R
    Y

    I
    S

    H

    *Com
    some systems with a statement “all others negative”.

    **Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.

    3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
    c) Initial Hospital Observation; d) Initial Nursing Facility Care.

    NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
    information about the PFSH. Please refer to procedure code descriptions.

    2. Examination

    Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
    Circle the type of examination within the appropriate grid in Section 5.

    Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM

    Affected body area or organ system and other symptomatic or related organ system(s)
    (additional systems up to total of 7)

    EXPANDED PROBLEM
    FOCUSED EXAM

    Extended exam of affected area(s) and other symptomatic or related organ system(s)
    (additional systems up to total of 7 or more depth than above) DETAILED EXAM

    General multi-system exam (8 or more systems) or complete exam of a single organ system
    (complete single exam not defined in these instructions) COMPREHENSIVE EXAM

    A
    M

    E
    X

    Body areas:
    q Head, including face q Chest, including breasts and axillae
    q Back, including spine qGenitalia, groin, buttocks

    Organ systems:

    q

    q

    Abdomen q Neck
    Each extremity

    q q q
    1 body
    area or
    system

    Up to 7
    systems

    Up to 7 8 or more
    systems systems

    q Constitutional q Ears,nose, q Resp q Musculo q Psych
    ) (e.g., vitals, gen app mouth, throat q GI q Skin

    q Eyes q Cardiovascular q GU q Neuro
    q Hem/lymph/imm

    PROBLEM
    FOCUSED

    EXP.PROB.
    FOCUSED DETAILED COMPRE-

    HENSIVE

    q

    – 1 –

    q

    q

    q

    3. Medical Decision Making

    Number of Diagnoses or Treatment Options

    Identify each problem or treatment option mentioned in the record.
    Enter the number in each of the categories in Column B in the table
    below. (There are maximum number in two categories.)

    Number of Diagnoses or Treatment Options
    A B X C = D

    Problem(s) Status Number Points Result

    Self-limited or minor
    (stable, improved or worsening) Max = 2 1
    Est. problem (to examiner); stable, improved 1

    Est. problem (to examiner); worsening 2

    New problem (to examiner); no additional
    workup planned

    Max = 1

    3

    New prob. (to examiner); add. workup planned 4

    TOTAL
    Multiply the number in columns B & C and put the product in column D.
    Enter a total for column D.

    Bring total to line A in Final Result for Complexity (table below)

    Amount and/or Complexity of Data Reviewed

    For each category of reviewed data identified, circle the number in the points
    column. Total the points.

    Amount and/or Complexity of Data Reviewed
    Reviewed Data Points

    1

    1

    1

    1

    1

    2

    2

    Review and/or order of clinical lab tests

    Review and/or order of tests in the radiology section of CPT

    Review and/or order of tests in the medicine section of CPT

    Discussion of test results with performing physician

    Decision to obtain old records and/or obtain history from
    someone other than patient

    Review and summarization of old records and/or obtaining
    history from someone other than patient and/or discussion of
    case with another health care provider

    Independent visualization of image, tracing or specimen itself
    (not simply review of report)

    TOTAL
    Bring total to line C in Final Result for Complexity (table below)

    Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
    contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
    most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
    Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality

    Level of
    Risk

    Presenting Problem(s) Diagnostic Procedure(s)
    Ordered

    Management Options
    Selected

    Minimal
    • One self-limited or minor problem,

    e.g., cold, insect bite, tinea corporis

    • Laboratory tests requiring venipuncture
    • Chest x-rays
    • EKG/EEG
    • Urinalysis
    • Ultrasound, e.g., echo
    • KOH prep

    • Rest
    • Gargles
    • Elastic bandages
    • Superficial dressings

    Low

    • Two or more self-limited or minor problems
    • One stable chronic illness, e.g., well controlled

    hypertension or non-insulin dependent diabetes,
    cataract, BPH

    • Acute uncomplicated illness or injury, e.g., cystitis, allergic
    rhinitis, simple sprain

    • Physiologic tests not under stress, e.g.,pulmonary
    function tests

    • Non-cardiovascular imaging studies with contrast,
    e.g., barium enema

    • Superficial needle biopsies
    • Clincal laboratory tests requiring arterial puncture
    • Skin biopsies

    • Over-the-counter drugs
    • Minor surgery with no identified risk factors
    • Physical therapy
    • Occupational therapy
    • IV fluids without additives

    Moderate

    • One or more chronic illnesses with mild exacerbation,
    progression, or side effects of treatment

    • Two or more stable chronic illnesses
    • Undiagnosed new problem with uncertain prognosis,
    e.g., lump in breast

    • Acute illness with systemic symptoms, e.g.,
    pyelonephritis, pneumonitis, colitis

    • Acute complicated injury, e.g., head injury with brief loss
    of consciousness

    • Physiologic tests under stress, e.g., cardiac stress test,
    fetal contraction stress test

    • Diagnostic endoscopies with no identified risk factors
    • Deep needle or incisional biopsy
    • Cardiovascular imaging studies with contrast and no

    identified risk factors, e.g., arteriogram cardiac cath
    • Obtain fluid from body cavity, e.g., lumbar puncture,

    thoracentesis, culdocentesis

    • Minor surgery with identified risk factors
    • Elective major surgery (open, percutaneous or

    endoscopic) with no identified risk factors
    • Prescription drug management
    • Therapeutic nuclear medicine
    • IV fluids with addititives
    • Closed treatment of fracture or dislocation without

    manipulation

    High

    • One or more chronic illnesses with severe exacerbation,
    progression, or side effects of treatment

    • Acute or chronic illnesses or injuries that may pose a threat to
    life or bodily function, e.g., multiple trauma, acute MI,
    pulmonary embolus, severe respiratory distress, progressive
    severe rheumatoid arthritis, psychiatric illness with potential
    threat to self or others, peritonitis, acute renal failure

    • An abrupt change in neurologic status, e.g., seizure, TIA,
    weakness or sensory loss

    • Cardiovascular imaging studies with contrast with
    identified risk factors

    • Cardiac electrophysiological tests
    • Diagnostic endoscopies with identified risk factors
    • Discography

    • Elective major surgery (open, percutaneous or
    endoscopic with identified risk factors)

    • Emergency major surgery (open, percutaneous or
    endoscopic)

    • Parenteral controlled substances
    • Drug therapy requiring intensive monitoring for toxicity
    • Decision not to resuscitate or to de-escalate care

    because of poor prognosis

    Final Result for Complexity
    Draw a line down any column with 2 or 3 circles to identify the type of decision making in
    that column. Otherwise, draw a line down the column with the 2nd circle from the left.
    After completing this table, which classifies complexity, circle the type of decision
    making within the appropriate grid in Section 5.

    Final Result for Complexity

    A Number diagnoses or
    treatment options

    ≤ 1
    Minimal

    2
    Limited

    3
    Multiple

    ≥ 4
    Extensive

    B Highest Risk Minimal Low Moderate High

    C Amount and complexity
    of data

    ≤ 1
    Minimal
    or low

    2
    Limited

    3
    Multiple

    ≥ 4
    Extensive

    Type of decision making STRAIGHT-
    FORWARD

    LOW
    COMPLEX.

    MODERATE
    COMPLEX.

    HIGH
    COMPLEX.

    4. Time

    If the physician documents total time and suggests that counseling or coordinating care dominates
    (more than 50%) the encounter, time may determine level of service. Documentation may refer to:
    prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk
    reduction or discussion with another health care provider.

    Face-to-face in outpatient setting
    Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No

    Does documentation describe the content of counseling or coordinating care? Yes No

    Does documentation reveal that more than half of the time was counseling or
    coordinating care? Yes No

    If all answers are "yes", select level based on time.

    – 2 –

    M
    E
    D
    I
    C
    A
    L

    D
    E
    C
    I
    S
    I
    O

    N

    M

    A
    K
    I
    N
    G

    5. L E V E L O F S E R V I C E

    New Office, Outpatient and Emergency Room
    New Office / Outpatient / ER Established Office / Outpatient
    Requires 3 components within shaded area Requires 2 components within shaded area

    History
    PF

    ER: PF
    EPF

    ER: EPF
    D

    ER: EPF
    C

    ER: D
    C

    ER: C Minimal
    problem
    that may
    not
    require
    presence
    of
    physician

    PF EPF D C

    Examination
    PF

    ER: PF

    EPF

    ER: EPF

    D

    ER: EPF

    C

    ER: D

    C

    ER: C
    PF EPF D C

    Complexity
    of medical
    decision

    SF
    ER: SF

    SF
    ER: L

    L
    ER: M

    M
    ER: M

    H
    ER: H SF L M H

    Average time
    (minutes)

    ER has no average
    time

    10 New (99201)

    ER (99281)

    20 New (99202)

    ER (99282)

    30 New (99203)

    ER (99283)

    45 New (99204)

    ER (99284)

    60 New (99205)

    ER (99285)

    5
    (99211)

    10
    (99212)

    15
    (99213)

    25
    (99214)

    40
    (99215)

    Level I II III IV V I II III IV V

    Hospital Care Initial Hospital/Observation Subsequent Hospital/Observation
    Requires 3 components within shaded area Requires 2 components within shaded area

    History D/C C C PF interval EPF interval D interval

    Examination D/C C C PF EPF D
    Complexity of medical

    decision SF/L M H SF/L M H

    Average time (minutes)
    30 Init hosp (99221)
    30 Init observ Care

    (99218)

    50 Init hosp (99222)
    50 Init observ Care

    (99219)

    70 Init hosp (99223)
    70 Init observ Care

    (99220)

    15 Sub hosp (99231)
    15 Sub observ care

    (99224)

    25 Sub hosp (99232)
    25 Sub observ care

    (99225)

    35 Sub hosp (99233)
    35 Sub observ care

    (99226)

    Level I II III I II III

    Nursing Facility
    Care Initial Nursing Facility

    Requires 3 components within shaded area
    Subsequent Nursing Facility
    Requires 2 components within shaded area

    Other Nursing Facility
    (Annual Assessment)

    Requires 3 components within shaded area

    History D/C C C PF interval EPF interval D interval C interval D interval

    Examination D/C C C PF EPF D C C

    Complexity of medical
    decision SF/L M H SF L M H L/M

    Average time (minutes) 25
    99304

    35
    99305

    45
    99306

    10
    99307

    15
    99308

    25
    99309

    35
    99310

    30
    99318

    Level I II III I II III IV

    Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care

    Requires 3 components within shaded area Requires 2 onents within shaded area

    History PF EPF D C C PF interval EPF interval D interval C interval

    Examination PF EPF D C C PF EPF D C
    Complexity of

    medical decision SF L M M H SF L M M/H
    Average time
    (minutes)

    20
    Domiciliary (99324)
    Home care (99341)

    30
    Domiciliary (99325)
    Home care (99342)

    45
    Domiciliary (99326)
    Home care (99343)

    60
    Domiciliary (99327)
    Home care (99344)

    75
    Domiciliary (99328)
    Home care (99345)

    15
    Domiciliary (99334)
    Home care (99347)

    25
    Domiciliary (99335)
    Home care (99348)

    40
    Domiciliary (99336)
    Home care (99349)

    60
    Domiciliary (99337)
    Home care (99350)

    Level I II III IV V I II III IV
    PF = Problem focused EPF = Expanded problem focused D = Detailed C = Comprehensive SF = Straightforward L = Low M = Moderate H = High

    – 3 –

    Establishe
    dcomp

    New

    – Novitas Solutions Documentation Worksheet
    – History Section
    – Examination Section
    – Medical Decision Making Section
    – Time Section
    – Level of Service Grids

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