· 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.
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK10Assgn1+last name+first initial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
NURS_6512_Week_10_Assignment1_Rubric
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NURS_6512_Week_10_Assignment1_Rubric
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Criteria
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Ratings
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Pts
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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.
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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.
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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.
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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.
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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.
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12 pts
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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.
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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.
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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.
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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.
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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.
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12 pts
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This criterion is linked to a Learning Outcome· Is
the assessment supported by the subjective and objective information? Why or
why not?
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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.
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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.
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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.
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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.
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16 pts
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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?
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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.
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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.
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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.
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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.
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20 pts
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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.
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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.
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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.
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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.
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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.
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25 pts
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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.
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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.
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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.
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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.
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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.
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5 pts
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This criterion is linked to a Learning OutcomeWritten Expression
and Formatting - English writing standards: Correct grammar, mechanics, and
proper punctuation
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5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
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4 to >3.0 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
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3 to >2.0 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
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2 to >0 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere
with the reader’s understanding.
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5 pts
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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.
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5 to >4.0 pts
Excellent
Uses correct APA format with no errors.
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4 to >3.0 pts
Good
Contains a few (1 or 2) APA format errors.
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3 to >2.0 pts
Fair
Contains several (3 or 4) APA format errors.
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2 to >0 pts
Poor
Contains many (≥ 5) APA format errors.
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5 pts
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Total Points: 100
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