Immersive Reader Unit 14 Assignment – Clinical: SOAP Note Instructions Every other week students will choose one patient encounter to submit a Follow-up SOAP note for review.

· NU674-7B

· Assignments

· Unit 14 Assignment – Clinical: SOAP Note

Immersive Reader

Unit 14 Assignment – Clinical: SOAP Note

Instructions

Every other week students will choose one patient encounter to submit a Follow-up SOAP note for review.

Follow the rubric to develop your SOAP notes for this term.

The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.

Rubric

NU674 Unit 14 Assignment – Clinical: SOAP Note

NU674 Unit 14 Assignment – Clinical: SOAP Note

Criteria

Ratings

Pts

This criterion is linked to a Learning
Outcome
Subjective Information

3 pts

Level
5

Complete
and concise summary of pertinent information.

2 pts

Level
3

Well
organized; partial but accurate summary of pertinent information (>80%).

1 pts

Level
1

Poorly
organized and/or limited summary of pertinent information (50%-80%);
information other than “S” provided.

0 pts

Level
0

Less
than 50% of pertinent information is addressed; or is grossly incomplete
and/or inaccurate.

3 pts

This criterion is linked to a Learning
Outcome
Objective Information

3 pts

Level
5

Complete
and concise summary of pertinent information.

2 pts

Level
3

Partial
but accurate summary of pertinent information (>80%).

1 pts

Level
1

Poorly
organized and/or limited summary of pertinent information (50%-80%);
information other than “O” provided.

0 pts

Level
0

Less
than 50% of pertinent information is addressed; or is grossly incomplete
and/or inaccurate.

3 pts

This criterion is linked to a Learning
Outcome
Assessment: Problem
Identification and Prioritization

3 pts

Level
5

Complete
problem list generated and rationally prioritized; no extraneous information
or issues listed.

2 pts

Level
3

Most
problems are identified and rationally prioritized, including the “main”
problem for the case (>80%).

1 pts

Level
1

Some
problems are identified (50%-80%); incomplete or inappropriate problem
prioritization; includes nonexistent problems or extraneous information
included.

0 pts

Level
0

Less
than 50% of problems are listed; or main problem missed; or problems not
prioritized and/or identified nonexistent problems.

3 pts

This criterion is linked to a Learning
Outcome
Assessment: Assessment of
Current Psychiatric & Medical Condition(s) or Drug Therapy-related
Problem

3 pts

Level
5

An
optimal and thorough assessment is present for each problem.

2 pts

Level
3

An
assessment is present for each problem listed but not optimal.

1 pts

Level
1

Assessment
is present for 50-80% of problems

0 pts

Level
0

Less
than 50% of problems include an appropriate assessment.

3 pts

This criterion is linked to a Learning
Outcome
Assessment: Treatment Goals

3 pts

Level
5

Appropriate
and relevant therapeutic goals for each identified problem.

2 pts

Level
3

Appropriate
therapeutic goals for most identified problems (>80%).

1 pts

Level
1

Appropriate
therapeutic goals for a few identified problems (50%-80%).

0 pts

Level
0

Less
than 50% of problems have appropriate therapeutic goals.

3 pts

This criterion is linked to a Learning
Outcome
Plan: Treatment Plan

3 pts

Level
5

Specific,
appropriate and justified recommendations (including drug name, strength,
route, frequency, and duration of therapy) for each identified problem.

2 pts

Level
3

Mostly
complete and appropriate for each identified problem (>80%).

1 pts

Level
1

Partially
complete and/or inappropriate for a few identified problems (50%-80%);
information other than “P” provided.

0 pts

Level
0

Less
than 50% of problems have an appropriate and complete treatment plan.

3 pts

This criterion is linked to a Learning
Outcome
Plan: Counseling, Referral,
Monitoring & Follow-up

2 pts

Level
5

Specific
patient education points, monitoring parameters, follow-up plan and (where
applicable) referral plan for each identified problem.

1 pts

Level
3

Patient
education points, monitoring parameters, follow-up plan and referral plan
(where applicable) for >80% of identified problems.

0.5 pts

Level
1

Patient
education points, monitoring parameters, follow-up plan and referral plan
(where applicable) for a few identified problems (50%-80%).

0 pts

Level
0

Less
than 50% of problems include appropriate counseling, monitoring, referral
and/or follow-up plan.

2 pts

Total Points: 20

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