This assignment provides a thorough analysis of a complex clinical encounter from your clinical experience this semester. Each student will select one patient seen in his/her clinical setting to use as the focus of the complex clinical case analysis. The patient must have a minimum of two chronic conditions. The documentation on this patient should meet requirements of comprehensive history and physical, high complexity decision-making, and moderate to high severity presenting problem (e.g., 99214 or 99215 level established outpatient visit, or 99233 or 99232 subsequent hospital care visit). The assignment reinforces a holistic view of the patient and the condition, and it encourages the APRN student to reflect on his/her practice.
Introduction:
Provide a brief introduction of the patient
Include age, race, gender, gender identification, type of insurance, and problem list for the visit
Pathophysiology/Assessment/Pharmacology:
For the top two conditions on the problem list
Provide an overview of the pathophysiology of the condition
Explain how pharmacological treatment that you choose addresses the pathology of the condition
Discuss the interaction(s) of the two conditions you are discussing in relation to pathophysiology, assessment, and pharmaceutical management
Scientific Foundation
Identify/discuss two current (less than 5 years old) evidence-based peer-reviewed research articles that are related to improving practice processes and outcomes for this patient.
Discuss a practice approach, based on the integration of the research you identified, related to this patient’s diagnosis.
Leadership
Discuss how you would advocate for improved access, quality, and cost effective care for patients with this diagnosis
Discuss how you could provide leadership to foster collaboration with multiple stakeholders (e.g., patients, community, integrated health care teams, and policy makers) to improve health care for patients with the same diagnosis.
Quality
Discuss how organizational structure, care processes, financing, marketing, and policy decisions impact the quality of health care for this patient.
Discuss how you could be proactive in implementing interventions to ensure quality of care for this patient.
Practice Inquiry
Identify and discuss the clinical guidelines related to your patient’s top two diagnoses.
Technology and Information Literacy
How could you integrate appropriate technologies for knowledge management to improve health care?
Policy
Analyze and discuss ethical policies that promote access, equity, quality, and cost for patients with this diagnosis.
Health Delivery System
Discuss how to minimize risk to the patient and provider at the individual and systems level.
Discuss how you would collaborate in planning for transitions across the continuum of care for this patient.
Ethics
Discuss any ethical principles in your decision making for this patient.
Independent Practice
How would you or did you create a climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and respect.
How would you or did you reserve the patient’s control over decision making by negotiating a mutually acceptable plan of care.
Formatting:
APA format
References < 5 years old or landmark studies
Length: 15 to 20 pages excluding title page, reference list, and appendices.
Well-organized with logical flow
Appropriate use of headings
Correct grammar and spelling
Written at Master’s degree level
Papers that have excessive use of quotations or include sections that are plagiarized may receive a grade of zero.
