NRP 531 Advanced Health Assessment

See below, attached instructions, scenario, and templates.

Week 5 Instructions

Wk 5 Episodic SOAP Note: Harold James Pt. 1

  1. This week focused on the overview of the anatomy of the brain, nervous systems, and additional variations in findings across the lifespan. It is time to practice your documentation skills by completing a SOAP Note for Harold James.
  2. Review the Harold James Scenario (see attached).
  3. Use the SOAP Note Template (see attached) and the SOAP Note Structure Guide (see attached) to develop your documentation needed to complete your SOAP Note.
  4. The assessment and plan sections will not be graded but should be completed to ensure documentation of a complete SOAP Note. You will also use this information to complete your E&M coding for the visit. Make sure to:
  5. Document all relevant information using appropriate terminology.NRP 531 Advanced Health Assessment
  6. List the appropriate ICD-10 codes and E&M codes using the diagnoses provided.
  7. This assignment must be completed in APA format, reference page in APA format, requires a minimum of 2 scholarly peer reviewed references.

Wk 5 Episodic SOAP Note: Harold James Pt. 2

  1. Well done, now that you have completed your SOAP Note for Harold James, 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.
  2. Write a 700-word reflection providing rationale for your completed SOAP Note. Consider the interview information provided in the patient scenario to do the following within your reflection:
  3. List 5 open-ended questions you would ask using descriptive language familiar to the patient during the HPI exam relevant to the chief complaint, including all pertinent and positive negatives. Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint.

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  4. Provide a minimum of 3 rationales for the physical exam components performed.
  5. Locate and review a current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis.
  6. Provide a brief summary of the article(s) in your reflection.
  7. 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, etc.).
  8. As the FNP, explain how you can address these barriers to improve the quality of care the patient receives.
  9. Use a minimum of 2 scholarly peer reviewed articles to support your answers.
  10. Cite the references used to support your assignment in APA format.

This entire assignment must be completed in APA format, reference page in APA format, requires a minimum total of 4 scholarly peer reviewed references.

Week 5 Instructions

Wk 5 Episodic SOAP Note: Harold James Pt. 1

  1. This week focused on the overview of the anatomy of the brain, nervous systems, and additional variations in findings across the lifespan. It is time to practice your documentation skills by completing a SOAP Note for Harold James.
  2. Review the Harold James Scenario (see attached).
  3. Use the SOAP Note Template (see attached) and the SOAP Note Structure Guide (see attached) to develop your documentation needed to complete your SOAP Note.
  4. The assessment and plan sections will not be graded but should be completed to ensure documentation of a complete SOAP Note. You will also use this information to complete your E&M coding for the visit. Make sure to:
  5. Document all relevant information using appropriate terminology.NRP 531 Advanced Health Assessment
  6. List the appropriate ICD-10 codes and E&M codes using the diagnoses provided.
  7. This assignment must be completed in APA format, reference page in APA format, requires a minimum of 2 scholarly peer reviewed references.

Wk 5 Episodic SOAP Note: Harold James Pt. 2

  1. Well done, now that you have completed your SOAP Note for Harold James, 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.
  2. Write a 700-word reflection providing rationale for your completed SOAP Note. Consider the interview information provided in the patient scenario to do the following within your reflection:
  3. List 5 open-ended questions you would ask using descriptive language familiar to the patient during the HPI exam relevant to the chief complaint, including all pertinent and positive negatives. Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint.
  4. Provide a minimum of 3 rationales for the physical exam components performed.
  5. Locate and review a current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis.
  6. Provide a brief summary of the article(s) in your reflection.
  7. 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, etc.).
  8. As the FNP, explain how you can address these barriers to improve the quality of care the patient receives.
  9. Use a minimum of 2 scholarly peer reviewed articles to support your answers.
  10. Cite the references used to support your assignment in APA format.NRP 531 Advanced Health Assessment