This week, you learned about the male genitourinary system and how to collect a proper history. It is time to practice your documentation skills. In this assignment, you write an episodic SOAP note for Craig Harris and reflect on potential barriers to care and evidence-based practices related to the diagnoses. Complete Parts 1 and 2 below.
Part 1: SOAP Note
Read the Craig Harris Scenario.
Use the SOAP Note Template and the SOAP Note Structure Guide to document your SOAP note for Craig Harris.
Please use the SOAP Note Template and the SOAP Note Structure Guide for this class. The templates are a little different from the NRP 531 class. I had students using different templates in my last NRP 571 class. đ We will practice this under the week 2 discussion.
11/11/2024 I added some additional data below. I am okay with you adding more data I just wanted to guide you a little. if this is helpful please use it. đ
Craig Harris Scenario
DOB: 2/1/1942
A 81-year-old /African American male nursing home resident is brought to your office with hesitancy in starting urinary stream, decreased force of the urinary stream, post-void dribbling, nocturia, and left lower quadrant (LLQ) abdominal pain for the past month. He doesn’t feel like he empties his bladder with each urination. He has problems with constipation and his last BM was one week ago. No fever. Nursing home staff says they aren’t sure if he is sexually active, but it does occur at the nursing home.
Past Medical History
Inguinal hernia
smoked 20 years
Family History
Colon Cancer Dad
Mom breast cancer BRCA
Social History
10th grade education
Retired Military
The caregiver who brought him to you asks if it would be all right to prescribe MiraLAXÂŽ. The caregiver only has a paper with his medications.
Ht: 72â Wt: 189 lb BMI: 25.6
Temp. 98 F HR: 74 Resp.: 16 BP: 130/70
Physical:
Thin elderly male
HEENT normal
Heart RRR
Lungs Clear
Abdomen soft BS times 4. Tender in the LLQ no rebound tenderness. Difficult to assess exactly in the LLQ where the pain is coming from. Negative CVA tenderness
Significant findings in objective exam include a 1 x 1 cm firm, hard nodule noted on the left lateral lobe of the prostate.
You can add to your examination as desired to assist your final diagnosis, just make sure you support it with references.
The assessment and plan sections will not be graded on accuracy, but should be completed to ensure documentation of a complete SOAP note and loss of points. We will start practicing this week using subjective and objective data to rule in or out differential diagnoses. I am not changing the assignment just trying to help you understand it better. đ Keep in mind the final diagnoses need to come from the differential diagnosis list not the problem list. The problem list is more of a fact gathering area. Often student get confused with the problem list, differential diagnoses list, and the final diagnoses.
You will also use this information to complete your E&M coding for the visit. Make sure to do the following:
Document all relevant information using appropriate terminology.
List the appropriate ICD-10 codes and E&M codes for the diagnoses.
Part 2: Reflection
Now that you have completed your SOAP note for Craig Harris, it is time for reflection. This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives.
Write a 700-word reflection providing a rationale for your completed SOAP note with consideration for the interview information provided in the patient scenario. Address the following in your reflection:
Locate and review at least 1 current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis. Provide a brief summary of the article(s).
Identify a minimum of 2 barriers to quality health care the patient can potentially experience per the information provided in the interview (e.g., cultural, linguistic, economic, previous conditions).
Explain how you, as the nurse practitioner, can address these barriers to improve the quality of care the patient receives.
Reference a minimum of 2 peer-reviewed articles to support your reflection.
There is no grading rubric so I split the points up below
Soap Note Template 7 points
Reflection:
Each bullet point is work 6 points each.
References 3 points
APA formatting 2 points see the announcement week 1 on APA formatting.
