· Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
· Based on the Episodic note case study:
o Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
o Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
o Consider what history would be necessary to collect from the patient in the case study.
o Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
THE LAB ASSIGNMENT
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
· Analyze the subjective portion of the note. List additional information that should be included in the documentation.
· Analyze the objective portion of the note. List additional information that should be included in the documentation.
· Is the assessment supported by the subjective and objective information? Why or why not?
· Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
· Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
BY DAY 7 OF WEEK 10
Submit your Assignment.
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Rubric
NURS_6512_Week_10_Assignment1_Rubric
NURS_6512_Week_10_Assignment1_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeWith regard to the
SOAP note case study provided and using evidence-based resources from your
search, answer the following questions and support your answers using current
evidence from the literature:· Analyze the subjective portion of
the note. List additional information that should be included in the
documentation.
12 to >9.0 pts
Excellent
The response clearly, accurately, and thoroughly analyzes the
subjective portion of the SOAP note and lists detailed additional
information to be included in the documentation.
9 to >6.0 pts
Good
The response accurately analyzes the subjective portion of the SOAP
note and lists additional information to be included in the documentation.
6 to >3.0 pts
Fair
The response vaguely analyzes the subjective portion of the SOAP note
and vaguely and/or inaccurately lists additional information to be included
in the documentation.
3 to >0 pts
Poor
The response inaccurately analyzes the subjective portion of the SOAP
note, with inaccurate and/or missing additional information included in the
documentation.
12 pts
This criterion is linked to a Learning Outcome·
Analyze the objective portion of the note. List additional information that
should be included in the documentation.
12 to >9.0 pts
Excellent
The response clearly, accurately, and thoroughly analyzes the
objective portion of the SOAP note and lists detailed additional
information to be included in the documentation.
9 to >6.0 pts
Good
The response accurately analyzes the objective portion of the SOAP
note and lists additional information to be included in the documentation.
6 to >3.0 pts
Fair
The response vaguely analyzes the objective portion of the SOAP note
and vaguely and/or inaccurately lists additional information to be included
in the documentation.
3 to >0 pts
Poor
The response inaccurately analyzes the objective portion of the SOAP
note, with inaccurate and/or missing additional information included in the
documentation.
12 pts
This criterion is linked to a Learning Outcome· Is
the assessment supported by the subjective and objective information? Why or
why not?
16 to >13.0 pts
Excellent
The response clearly and accurately identifies whether or not the
assessment is supported by the subjective and/or objective information,
with a thorough and detailed explanation.
13 to >10.0 pts
Good
The response accurately identifies whether or not the assessment is
supported by the subjective and/or objective information, with a clear
explanation.
10 to >7.0 pts
Fair
The response vaguely identifies whether or not the assessment is
supported by the subjective and/or objective information, with a vague
explanation.
7 to >0 pts
Poor
The response inaccurately identifies whether or not the assessment is
supported by the subjective and/or objective information, with an
inaccurate or missing explanation.
16 pts
This criterion is linked to a Learning Outcome· What
diagnostic tests would be appropriate for this case, and how would the results
be used to make a diagnosis?
20 to >17.0 pts
Excellent
The response thoroughly and accurately describes appropriate
diagnostic tests for the case and explains clearly, thoroughly, and
accurately how the test results would be used to make a diagnosis.
17 to >14.0 pts
Good
The response accurately describes appropriate diagnostic tests for
the case and explains how the test results would be used to make a
diagnosis.
14 to >11.0 pts
Fair
The response vaguely and/or with some inaccuracy describes appropriate
diagnostic tests for the case and vaguely and/or with some inaccuracy
explains how the test results would be used to make a diagnosis.
11 to >0 pts
Poor
The response inaccurately describes appropriate diagnostic tests for
the case, with an inaccurate or missing explanation of how the test results
would be used to make a diagnosis.
20 pts
This criterion is linked to a Learning Outcome·
Would you reject or accept the current diagnosis? Why or why not?·
Identify three possible conditions that may be considered as a differenial
diagnosis for this patient. Explain your reasoning using at least three
different references from current evidence-based literature.
25 to >22.0 pts
Excellent
The response states clearly whether to accept or reject the current
diagnosis, with a thorough, accurate, and detailed explanation of sound
reasoning. The response clearly, thoroughly, and accurately identifies
three conditions as a differential diagnosis, with reasoning that is
explained clearly, accurately, and thoroughly using three or more different
references from current evidence-based literature.
22 to >19.0 pts
Good
The response states whether to accept or reject the current
diagnosis, with an accurate explanation of sound reasoning. The response
accurately identifies three conditions as a differential diagnosis, with
reasoning that is explained using three different references from current
evidence-based literature.
19 to >16.0 pts
Fair
The response states whether to accept or reject the current
diagnosis, with a vague explanation of the reasoning. The response
identifies two to three conditions as a differential diagnosis, with
reasoning that is explained vaguely and/or inaccurately using three or
fewer references from current evidence-based literature.
16 to >0 pts
Poor
The response inaccurately states or is missing a statement of whether
to accept or reject the current diagnosis, with an explanation that is
inaccurate and/or missing. The response identifies three or fewer
conditions as a differential diagnosis, with reasoning that is missing or
explained inaccurately using two or fewer references from current
evidence-based literature.
25 pts
This criterion is linked to a Learning OutcomeWritten Expression
and Formatting – Paragraph Development and Organization: Paragraphs make
clear points that support well-developed ideas, flow logically, and
demonstrate continuity of ideas. Sentences are carefully focused–neither
long and rambling nor short and lacking substance. A clear and comprehensive
purpose statement and introduction are provided that delineate all required
criteria.
5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity. A clear and comprehensive purpose statement,
introduction, and conclusion are provided that delineate all required
criteria.
4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity 80% of the time. Purpose, introduction, and
conclusion of the assignment are stated, yet are brief and not descriptive.
3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity 60%–79% of the time. Purpose, introduction, and
conclusion of the assignment are vague or off topic.
2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity < 60% of the time. No purpose statement,
introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression
and Formatting – English writing standards: Correct grammar, mechanics, and
proper punctuation
5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
2 to >0 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere
with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression
and Formatting – The paper follows correct APA format for title page,
headings, font, spacing, margins, indentations, page numbers, running
heads, parenthetical/in-text citations, and reference list.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) APA format errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) APA format errors.
2 to >0 pts
Poor
Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100
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