Category: Nursing

[Solved] PEDS wk5 DB

✓ Verified Academic Solution Available

Executive Solution Overview

– ## Week5DB.docx **## Week5DB.docx** **Week 5 Discussion Part I** **Table 1** **Classifications of Anemias** | | | | | | | — | — | — | — | — | | Complete the information. | | | Normocytic | Microcytic | Macrocytic | Hemolytic Anemia | | Description | | | | | | Clinical Findings | | | | | …

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

– ## Week5DB.docx

**## Week5DB.docx**

**Week 5 Discussion Part I**

**Table 1**

**Classifications of Anemias**

| | | | | |
| — | — | — | — | — |
| Complete the information. |
| | Normocytic | Microcytic | Macrocytic | Hemolytic Anemia |
| Description | | | | |
| Clinical Findings | | | | |
| Diagnostic Studies | | | | |
| Management | | | | |

**Table 2**

**Differentiate Common Childhood Leukemias**

| | | |
| — | — | — |
| Clinical Findings: |
| | Acute Lymphocytic Leukemia (ALL) | Acute Myelogenous Leukemia (AML) |
| Occurrence | | |
| Management | | |

**Table 3**

**Tanner Stages**

| | | |
| — | — | — |
| Tanner Stages | Girls <br>(Breast Development) | Boys <br>(Genital Development- testes/penis) |
| Stage I | | |
| Stage II | | |
| Stage III | | |
| Stage IV | | |
| Stage V | | |

**Table 4**

**Delayed Puberty, Menarche, and Growth Spurts**

| |
| — |
| Answer the following questions. |
| How is precocious puberty defined for boys and girls? |
| |
| What is considered delayed puberty in boys and girls? |
| |
| What labs tests should be ordered for delayed puberty? |
| |
| During what age ranges do growth spurts occur in boys and girls? |
| |
| What is the average age of menarche in the United States? |
| |

**Table 5**

**Differentiate Types of Diabetes**

| | | |
| — | — | — |
| | Type 1 Diabetes | Type 2 Diabetes |
| Age of onset | | |
| Gender | | |
| Race/Ethnicity | | |
| Obesity | | |
| Family History of DM | | |
| Insulin Secretion | | |
| Insulin Sensitivity | | |
| Onset | | |
| Ketosis, DKA | | |
| Hypertension | | |
| Acanthosis nigricans | | |
| Polycystic ovarian syndrome | | |
| Islet Autoimmunity | | |

**Table 6**

**Hypothyroidism and Hyperthyroidism**

| | | | |
| — | — | — | — |
| Differentiate between hypothyroidism and hyperthyroidism |
| | Clinical Findings | Diagnostic Studies | Management |
| Hypothyroidism | | | |
| Hyperthyroidism | | | |

**Table 7**

**Drug Interaction with Herbal Supplements**

| | | |
| — | — | — |
| Please complete the table of common interactions between FDA-approved medications and herbal supplements |
| Drug Category | Herb | Effect of Herb on the Drug’s Action |
| Iron | Tannin-rich herbs (e.g. caffeine containing herbs, cat’s claw, tea, uva, ursi) | |
| Laxative, stimulant (e.g., bisacodyl) | Aloe, cascara sagrada, senna, yellow dock | |
| NSAIDS | Gastric irritant herbs (e.g. caffeine, rue, uva ursi)<br>Nettles | |
| Oral contraceptives | Licorice, St. John’s wort | |
| Salicylates (e.g. aspirin) | Herbs that alkalinize urine (e.g. uva ursi)<br>Tamarind<br>Ginkgo, garlic | |
| Theophyline | St. John’s wort | |
| Thyroid Hormone | Horseradish<br>Kelp | |

**PART II**

Select one of the following four case scenarios. Identify the prompt in the subject line of your post, for example, Case Scenario 1 – Tommy

Complete all Part II elements of the discussion:

· Each prompt has additional key questions to address in the body of your response to ensure an understanding of learning objectives.

· Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.

· In your peer replies, please reply to at least two peers who chose a different case scenario – other than the one you selected. For example, if you selected Case Scenario 1, then reply to one peer who selected Case Scenario 2 and another peer who selected Case Scenario 3 or 4.

· Be prepared to answer additional questions relating to a secondary diagnosis or consideration posed by faculty.

**Case Scenario 2:** Margaret brought in her 11-year-old daughter Sandy for her well-child exam. Sandy has developed axillary and pubic hair and has been complaining of mild abdominal cramping off and on for 3 days. Margaret also mentions to you that she is concerned about allowing her daughter to participate in a sexuality educational course offered at school.

· What does the evidence say about providing sexuality education at school to children?

· Which approach should you take when taking a sexual history from Sandy?

· What anticipatory guidance should you give Sandy about her body changes?

· What anticipatory guidance should you give Margaret about teaching Sandy about sex?

**## Week5DB.docx**

**Week 5 Discussion Part I**

**Table 1**

**Classifications of Anemias**

| | | | | |
| — | — | — | — | — |
| Complete the information. |
| | Normocytic | Microcytic | Macrocytic | Hemolytic Anemia |
| Description | | | | |
| Clinical Findings | | | | |
| Diagnostic Studies | | | | |
| Management | | | | |

**Table 2**

**Differentiate Common Childhood Leukemias**

| | | |
| — | — | — |
| Clinical Findings: |
| | Acute Lymphocytic Leukemia (ALL) | Acute Myelogenous Leukemia (AML) |
| Occurrence | | |
| Management | | |

**Table 3**

**Tanner Stages**

| | | |
| — | — | — |
| Tanner Stages | Girls <br>(Breast Development) | Boys <br>(Genital Development- testes/penis) |
| Stage I | | |
| Stage II | | |
| Stage III | | |
| Stage IV | | |
| Stage V | | |

**Table 4**

**Delayed Puberty, Menarche, and Growth Spurts**

| |
| — |
| Answer the following questions. |
| How is precocious puberty defined for boys and girls? |
| |
| What is considered delayed puberty in boys and girls? |
| |
| What labs tests should be ordered for delayed puberty? |
| |
| During what age ranges do growth spurts occur in boys and girls? |
| |
| What is the average age of menarche in the United States? |
| |

**Table 5**

**Differentiate Types of Diabetes**

| | | |
| — | — | — |
| | Type 1 Diabetes | Type 2 Diabetes |
| Age of onset | | |
| Gender | | |
| Race/Ethnicity | | |
| Obesity | | |
| Family History of DM | | |
| Insulin Secretion | | |
| Insulin Sensitivity | | |
| Onset | | |
| Ketosis, DKA | | |
| Hypertension | | |
| Acanthosis nigricans | | |
| Polycystic ovarian syndrome | | |
| Islet Autoimmunity | | |

**Table 6**

**Hypothyroidism and Hyperthyroidism**

| | | | |
| — | — | — | — |
| Differentiate between hypothyroidism and hyperthyroidism |
| | Clinical Findings | Diagnostic Studies | Management |
| Hypothyroidism | | | |
| Hyperthyroidism | | | |

**Table 7**

**Drug Interaction with Herbal Supplements**

| | | |
| — | — | — |
| Please complete the table of common interactions between FDA-approved medications and herbal supplements |
| Drug Category | Herb | Effect of Herb on the Drug’s Action |
| Iron | Tannin-rich herbs (e.g. caffeine containing herbs, cat’s claw, tea, uva, ursi) | |
| Laxative, stimulant (e.g., bisacodyl) | Aloe, cascara sagrada, senna, yellow dock | |
| NSAIDS | Gastric irritant herbs (e.g. caffeine, rue, uva ursi)<br>Nettles | |
| Oral contraceptives | Licorice, St. John’s wort | |
| Salicylates (e.g. aspirin) | Herbs that alkalinize urine (e.g. uva ursi)<br>Tamarind<br>Ginkgo, garlic | |
| Theophyline | St. John’s wort | |
| Thyroid Hormone | Horseradish<br>Kelp | |

**PART II**

Select one of the following four case scenarios. Identify the prompt in the subject line of your post, for example, Case Scenario 1 – Tommy

Complete all Part II elements of the discussion:

· Each prompt has additional key questions to address in the body of your response to ensure an understanding of learning objectives.

· Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.

· In your peer replies, please reply to at least two peers who chose a different case scenario – other than the one you selected. For example, if you selected Case Scenario 1, then reply to one peer who selected Case Scenario 2 and another peer who selected Case Scenario 3 or 4.

· Be prepared to answer additional questions relating to a secondary diagnosis or consideration posed by faculty.

**Case Scenario 2:** Margaret brought in her 11-year-old daughter Sandy for her well-child exam. Sandy has developed axillary and pubic hair and has been complaining of mild abdominal cramping off and on for 3 days. Margaret also mentions to you that she is concerned about allowing her daughter to participate in a sexuality educational course offered at school.

· What does the evidence say about providing sexuality education at school to children?

· Which approach should you take when taking a sexual history from Sandy?

· What anticipatory guidance should you give Sandy about her body changes?

· What anticipatory guidance should you give Margaret about teaching Sandy about sex?

November 5, 2026
[Solved] problem focused PED NOTE wk5

✓ Verified Academic Solution Available

Executive Solution Overview

– ## Problemfocusedsoapnotetemplate.docx **## Problemfocusedsoapnotetemplate.docx** Problem-focused SOAP Note Format _Demographic Data_ · Age, and gender (must be HIPAA compliant) _Subjective_ · Chief Complaint (CC): A short statement about why they are there · History of Present Illness (HPI): Writ…

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

– ## Problemfocusedsoapnotetemplate.docx

**## Problemfocusedsoapnotetemplate.docx**

Problem-focused SOAP Note Format

_Demographic Data_

· Age, and gender (must be HIPAA compliant)

_Subjective_

· Chief Complaint (CC): A short statement about why they are there

· History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment

· Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance

· Family Hx: any history of CA, DM, HTN, MI, CVA?

· Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.

· Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

_Objective_

· Vital Signs

· Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

_Assessment (the diagnosis)_

· At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each

· Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

_Plan_

· Dx Plan (lab, x-ray)

· Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)

· Pt. Education, including specific medication teaching points

· Referral/Follow-up

· Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

_Reference_

· Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

**## Problemfocusedsoapnotetemplate.docx**

Problem-focused SOAP Note Format

_Demographic Data_

· Age, and gender (must be HIPAA compliant)

_Subjective_

· Chief Complaint (CC): A short statement about why they are there

· History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment

· Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance

· Family Hx: any history of CA, DM, HTN, MI, CVA?

· Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.

· Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

_Objective_

· Vital Signs

· Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

_Assessment (the diagnosis)_

· At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each

· Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

_Plan_

· Dx Plan (lab, x-ray)

· Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)

· Pt. Education, including specific medication teaching points

· Referral/Follow-up

· Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

_Reference_

· Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

November 5, 2026
[Solved] Organizational Culture and Climate: Assessment and Analysis

✓ Verified Academic Solution Available

Executive Solution Overview

please find attachments – ## Week_5_Rubric.docx – Week5Assessment.docx **## Week_5_Rubric.docx** Week 5: Organizational Culture and Climate: Assessment and Analysis Assignment Guidelines with Scoring Rubric ## Purpose: The purpose of this assignment is to explore the culture and climate of the h…

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

please find attachments

– ## Week_5_Rubric.docx

– Week5Assessment.docx

**## Week_5_Rubric.docx**

Week 5: Organizational Culture and Climate: Assessment and Analysis

Assignment Guidelines with Scoring Rubric

## Purpose:

The purpose of this assignment is to explore the culture and climate of the healthcare organization and its impact on providing a healthy, safe, and person-centered care and work environment. (CO 1,3,6)

## Requirements

**Description of the Assignment**

This assignment provides an opportunity for the student to

· Assess organizational culture and climate within a healthcare organization known to the student

· Analyze the organizational culture and climate for its strengths and opportunities for improvement

· Determine the organization’s capacity to provide a healthy, safe, person-centered environment for staff and patients based on its culture and climate

· Reflect on the “fit” of personal leadership profile with the organization’s culture and climate

## Preparing the Assignment

**Requirements:**

1. Address all components of the Organizational Culture and Climate Assessment and Analysis Paper as outlined under
**“Assignment Directions and Criteria**”.

2. The paper is graded on quality and completeness of information, depth of thought, organization following the outline provided, substantive narrative, use of citations, use of standard English, and writing conventions.

3. Format:

a. APA format, using most current edition, is required for citations and references in this assignment

i. Required elements

1. Title page, reference page

2.
Page numbers, doubles-spaced, times new roman, 12pt font, 1” margins, level 1 headings

3.
**Paper length: 6 pages maximum, best 5 pages**, excluding reference page, title page, and assessment tool

ii.
**Scholarly sources: Minimum of four (4) scholarly resources no older than 5 years**

iii. Proof-reading

1. Use spell check and grammar check and correct all errors

2. Compare final draft to detailed outline directions to ensure all required elements included

**DIRECTIONS AND ASSIGNMENT CRITERIA**

**This assignment has two steps and requires that you do an actual assessment and analysis of the healthcare organization within which you work.**

**Step 1: The Assessment Tool – this part is done please check another attachment paper !**

**Complete the Organizational Culture and Climate Assessment Tool. The tool is your data collection tool, or “notes-taking” pages you will need to complete before doing the analysis. You may already know some of the information, but some may require communication with key people in the organization, for example, human resources, financial officers, or nurse executives. Submitting the completed tool with your final paper submission is required. It is not included in your page count. You receive credit for completing and submitting it the items in the following outline.**

**Step 2: The Analysis**

**Analyze the findings from your assessment following the outline below. (See the rubric for specific criteria within each section) Support your analysis and conclusions with specific evidence from your assessment and scholarly sources. The paper will contain the following components with headings as required. (Remember, no heading is used for the introduction section)**

**Write on the basis of Sentara Obici Hospital at Suffolk Virginia**

I.
**Introduction**

a.
**Stated purpose**

b.
**Definition of organizational culture vs climate**

c.
**Broad overview of components of the paper**

II.
**Organizational culture and climate analysis**

a.
**Summary of assessment findings**

b.
**Mission, vision, and goals reflected in culture and climate – please find the attach link to know more about organization**

[**https://www.sentara.com/hospitalslocations/sentara-obici-hospital**](https://www.sentara.com/hospitalslocations/sentara-obici-hospital)

[**https://obicihcf.org/who-we-are/**](https://obicihcf.org/who-we-are/)

[**https://www.sentaracareers.com/explore-sentara/mission-vision-values-history/**](https://www.sentaracareers.com/explore-sentara/mission-vision-values-history/)

c.
**Strengths and Opportunities for Improvement**

d.
**Climate reflective of culture**

III.
**Healthy, safe, person-centered care environment capacity**

a.
**Describe the organizational culture’s capacity to support**

b.
**What would a visiting potential staff recruit experience about the institution’s culture that would attract them to work there?**

c.
**Nurse leader’s role in setting the organizational culture and climate to promote a healthy work environment?**

IV.
**Implications**

a.
**Two strategies to address the opportunities for improvement**

b.
**Alignment of Personal Leadership Profile and Organizational Culture and Climate**

V.
**Conclusion**

a.
**Broadly address the what has been accomplished in the paper**

b.
**Benefits of the completing the assignment**

| | | | |
| — | — | — | — |
| Category | Points | % | Description |
| |
| Introduction | **10** | **10%** | Purpose stated, organizational culture and climate defined; broad overview of components of paper |
| Organizational Culture and Climate Assessment Tool | **15** | **15%** | All elements addressed; document included with final paper submission |
| Analysis: Element 1<br> <br>**Organizational Culture and Climate Description** | **20** | **20** | **Organizational culture at the institution described using general categories from assessment and include: Physical environment; social environment; professional and personal support; organizational power structures; environmental safety; organizational communication; organizational taboos** |
| Analysis: Element 2<br> <br>**Mission, vision, and goals** | **20** | **20** | **Organizational Mission, vision, goals specifically align to reflect categories of organizational culture and include**<br>**Physical environment; social environment; professional and personal support; organizational power structures; environmental safety; organizational communication; organizational taboos** |
| Analysis: Element 3<br> <br>**Strengths and Opportunities for improvement** | **20** | | **Minimum of three strengths of organizational culture described;**<br>**Minimum of two major opportunities for improvement described** |
| Analysis: Element 4<br> <br>**Climate reflective of culture** | **20** | | **Description of organizational climate including at least two ways in which it specifically reflects the organizational culture** |
| **Healthy, safe, person-centered care capacity** | **15** | | **Organization culture and climate capacity to support healthy, safe, person-centered healthcare work environment; Capacity for attracting staff; Impact on nurse recruitment; Nurse leader role in setting culture and climate** |
| **Implications** | **10** | | Strategies to address the identified opportunities for improvement<br>Personal Leadership Profile and Organizational Culture and Climate Alignment |
| **Conclusion** | **10** | | Broadly address the what has been accomplished in the paper<br>Benefits of the completing the assignment |
| Writing conventions, format, and reference citations | **10** | | **Writing is clear concise without grammatical and spelling errors. All references are correctly cited (if applicable) and written.** |
| | | | **A quality assignment will meet or exceed all of the above requirements.** |

NR 534 Week 5: Assignment: Culture and Climate 02_21_19nhs

1

**Week5Assessment.docx**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/week5assessment-docx-10311557)

**Week5Assessment.docx**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/week5assessment-docx-10311557)

**## Week_5_Rubric.docx**

Week 5: Organizational Culture and Climate: Assessment and Analysis

Assignment Guidelines with Scoring Rubric

## Purpose:

The purpose of this assignment is to explore the culture and climate of the healthcare organization and its impact on providing a healthy, safe, and person-centered care and work environment. (CO 1,3,6)

## Requirements

**Description of the Assignment**

This assignment provides an opportunity for the student to

· Assess organizational culture and climate within a healthcare organization known to the student

· Analyze the organizational culture and climate for its strengths and opportunities for improvement

· Determine the organization’s capacity to provide a healthy, safe, person-centered environment for staff and patients based on its culture and climate

· Reflect on the “fit” of personal leadership profile with the organization’s culture and climate

## Preparing the Assignment

**Requirements:**

1. Address all components of the Organizational Culture and Climate Assessment and Analysis Paper as outlined under
**“Assignment Directions and Criteria**”.

2. The paper is graded on quality and completeness of information, depth of thought, organization following the outline provided, substantive narrative, use of citations, use of standard English, and writing conventions.

3. Format:

a. APA format, using most current edition, is required for citations and references in this assignment

i. Required elements

1. Title page, reference page

2.
Page numbers, doubles-spaced, times new roman, 12pt font, 1” margins, level 1 headings

3.
**Paper length: 6 pages maximum, best 5 pages**, excluding reference page, title page, and assessment tool

ii.
**Scholarly sources: Minimum of four (4) scholarly resources no older than 5 years**

iii. Proof-reading

1. Use spell check and grammar check and correct all errors

2. Compare final draft to detailed outline directions to ensure all required elements included

**DIRECTIONS AND ASSIGNMENT CRITERIA**

**This assignment has two steps and requires that you do an actual assessment and analysis of the healthcare organization within which you work.**

**Step 1: The Assessment Tool – this part is done please check another attachment paper !**

**Complete the Organizational Culture and Climate Assessment Tool. The tool is your data collection tool, or “notes-taking” pages you will need to complete before doing the analysis. You may already know some of the information, but some may require communication with key people in the organization, for example, human resources, financial officers, or nurse executives. Submitting the completed tool with your final paper submission is required. It is not included in your page count. You receive credit for completing and submitting it the items in the following outline.**

**Step 2: The Analysis**

**Analyze the findings from your assessment following the outline below. (See the rubric for specific criteria within each section) Support your analysis and conclusions with specific evidence from your assessment and scholarly sources. The paper will contain the following components with headings as required. (Remember, no heading is used for the introduction section)**

**Write on the basis of Sentara Obici Hospital at Suffolk Virginia**

I.
**Introduction**

a.
**Stated purpose**

b.
**Definition of organizational culture vs climate**

c.
**Broad overview of components of the paper**

II.
**Organizational culture and climate analysis**

a.
**Summary of assessment findings**

b.
**Mission, vision, and goals reflected in culture and climate – please find the attach link to know more about organization**

[**https://www.sentara.com/hospitalslocations/sentara-obici-hospital**](https://www.sentara.com/hospitalslocations/sentara-obici-hospital)

[**https://obicihcf.org/who-we-are/**](https://obicihcf.org/who-we-are/)

[**https://www.sentaracareers.com/explore-sentara/mission-vision-values-history/**](https://www.sentaracareers.com/explore-sentara/mission-vision-values-history/)

c.
**Strengths and Opportunities for Improvement**

d.
**Climate reflective of culture**

III.
**Healthy, safe, person-centered care environment capacity**

a.
**Describe the organizational culture’s capacity to support**

b.
**What would a visiting potential staff recruit experience about the institution’s culture that would attract them to work there?**

c.
**Nurse leader’s role in setting the organizational culture and climate to promote a healthy work environment?**

IV.
**Implications**

a.
**Two strategies to address the opportunities for improvement**

b.
**Alignment of Personal Leadership Profile and Organizational Culture and Climate**

V.
**Conclusion**

a.
**Broadly address the what has been accomplished in the paper**

b.
**Benefits of the completing the assignment**

| | | | |
| — | — | — | — |
| Category | Points | % | Description |
| |
| Introduction | **10** | **10%** | Purpose stated, organizational culture and climate defined; broad overview of components of paper |
| Organizational Culture and Climate Assessment Tool | **15** | **15%** | All elements addressed; document included with final paper submission |
| Analysis: Element 1<br> <br>**Organizational Culture and Climate Description** | **20** | **20** | **Organizational culture at the institution described using general categories from assessment and include: Physical environment; social environment; professional and personal support; organizational power structures; environmental safety; organizational communication; organizational taboos** |
| Analysis: Element 2<br> <br>**Mission, vision, and goals** | **20** | **20** | **Organizational Mission, vision, goals specifically align to reflect categories of organizational culture and include**<br>**Physical environment; social environment; professional and personal support; organizational power structures; environmental safety; organizational communication; organizational taboos** |
| Analysis: Element 3<br> <br>**Strengths and Opportunities for improvement** | **20** | | **Minimum of three strengths of organizational culture described;**<br>**Minimum of two major opportunities for improvement described** |
| Analysis: Element 4<br> <br>**Climate reflective of culture** | **20** | | **Description of organizational climate including at least two ways in which it specifically reflects the organizational culture** |
| **Healthy, safe, person-centered care capacity** | **15** | | **Organization culture and climate capacity to support healthy, safe, person-centered healthcare work environment; Capacity for attracting staff; Impact on nurse recruitment; Nurse leader role in setting culture and climate** |
| **Implications** | **10** | | Strategies to address the identified opportunities for improvement<br>Personal Leadership Profile and Organizational Culture and Climate Alignment |
| **Conclusion** | **10** | | Broadly address the what has been accomplished in the paper<br>Benefits of the completing the assignment |
| Writing conventions, format, and reference citations | **10** | | **Writing is clear concise without grammatical and spelling errors. All references are correctly cited (if applicable) and written.** |
| | | | **A quality assignment will meet or exceed all of the above requirements.** |

NR 534 Week 5: Assignment: Culture and Climate 02_21_19nhs

1

**Week5Assessment.docx**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/week5assessment-docx-10311557)

**## Week_5_Rubric.docx**

Week 5: Organizational Culture and Climate: Assessment and Analysis

Assignment Guidelines with Scoring Rubric

## Purpose:

The purpose of this assignment is to explore the culture and climate of the healthcare organization and its impact on providing a healthy, safe, and person-centered care and work environment. (CO 1,3,6)

## Requirements

**Description of the Assignment**

This assignment provides an opportunity for the student to

· Assess organizational culture and climate within a healthcare organization known to the student

· Analyze the organizational culture and climate for its strengths and opportunities for improvement

· Determine the organization’s capacity to provide a healthy, safe, person-centered environment for staff and patients based on its culture and climate

· Reflect on the “fit” of personal leadership profile with the organization’s culture and climate

## Preparing the Assignment

**Requirements:**

1. Address all components of the Organizational Culture and Climate Assessment and Analysis Paper as outlined under
**“Assignment Directions and Criteria**”.

2. The paper is graded on quality and completeness of information, depth of thought, organization following the outline provided, substantive narrative, use of citations, use of standard English, and writing conventions.

3. Format:

a. APA format, using most current edition, is required for citations and references in this assignment

i. Required elements

1. Title page, reference page

2.
Page numbers, doubles-spaced, times new roman, 12pt font, 1” margins, level 1 headings

3.
**Paper length: 6 pages maximum, best 5 pages**, excluding reference page, title page, and assessment tool

ii.
**Scholarly sources: Minimum of four (4) scholarly resources no older than 5 years**

iii. Proof-reading

1. Use spell check and grammar check and correct all errors

2. Compare final draft to detailed outline directions to ensure all required elements included

**DIRECTIONS AND ASSIGNMENT CRITERIA**

**This assignment has two steps and requires that you do an actual assessment and analysis of the healthcare organization within which you work.**

**Step 1: The Assessment Tool – this part is done please check another attachment paper !**

**Complete the Organizational Culture and Climate Assessment Tool. The tool is your data collection tool, or “notes-taking” pages you will need to complete before doing the analysis. You may already know some of the information, but some may require communication with key people in the organization, for example, human resources, financial officers, or nurse executives. Submitting the completed tool with your final paper submission is required. It is not included in your page count. You receive credit for completing and submitting it the items in the following outline.**

**Step 2: The Analysis**

**Analyze the findings from your assessment following the outline below. (See the rubric for specific criteria within each section) Support your analysis and conclusions with specific evidence from your assessment and scholarly sources. The paper will contain the following components with headings as required. (Remember, no heading is used for the introduction section)**

**Write on the basis of Sentara Obici Hospital at Suffolk Virginia**

I.
**Introduction**

a.
**Stated purpose**

b.
**Definition of organizational culture vs climate**

c.
**Broad overview of components of the paper**

II.
**Organizational culture and climate analysis**

a.
**Summary of assessment findings**

b.
**Mission, vision, and goals reflected in culture and climate – please find the attach link to know more about organization**

[**https://www.sentara.com/hospitalslocations/sentara-obici-hospital**](https://www.sentara.com/hospitalslocations/sentara-obici-hospital)

[**https://obicihcf.org/who-we-are/**](https://obicihcf.org/who-we-are/)

[**https://www.sentaracareers.com/explore-sentara/mission-vision-values-history/**](https://www.sentaracareers.com/explore-sentara/mission-vision-values-history/)

c.
**Strengths and Opportunities for Improvement**

d.
**Climate reflective of culture**

III.
**Healthy, safe, person-centered care environment capacity**

a.
**Describe the organizational culture’s capacity to support**

b.
**What would a visiting potential staff recruit experience about the institution’s culture that would attract them to work there?**

c.
**Nurse leader’s role in setting the organizational culture and climate to promote a healthy work environment?**

IV.
**Implications**

a.
**Two strategies to address the opportunities for improvement**

b.
**Alignment of Personal Leadership Profile and Organizational Culture and Climate**

V.
**Conclusion**

a.
**Broadly address the what has been accomplished in the paper**

b.
**Benefits of the completing the assignment**

| | | | |
| — | — | — | — |
| Category | Points | % | Description |
| |
| Introduction | **10** | **10%** | Purpose stated, organizational culture and climate defined; broad overview of components of paper |
| Organizational Culture and Climate Assessment Tool | **15** | **15%** | All elements addressed; document included with final paper submission |
| Analysis: Element 1<br> <br>**Organizational Culture and Climate Description** | **20** | **20** | **Organizational culture at the institution described using general categories from assessment and include: Physical environment; social environment; professional and personal support; organizational power structures; environmental safety; organizational communication; organizational taboos** |
| Analysis: Element 2<br> <br>**Mission, vision, and goals** | **20** | **20** | **Organizational Mission, vision, goals specifically align to reflect categories of organizational culture and include**<br>**Physical environment; social environment; professional and personal support; organizational power structures; environmental safety; organizational communication; organizational taboos** |
| Analysis: Element 3<br> <br>**Strengths and Opportunities for improvement** | **20** | | **Minimum of three strengths of organizational culture described;**<br>**Minimum of two major opportunities for improvement described** |
| Analysis: Element 4<br> <br>**Climate reflective of culture** | **20** | | **Description of organizational climate including at least two ways in which it specifically reflects the organizational culture** |
| **Healthy, safe, person-centered care capacity** | **15** | | **Organization culture and climate capacity to support healthy, safe, person-centered healthcare work environment; Capacity for attracting staff; Impact on nurse recruitment; Nurse leader role in setting culture and climate** |
| **Implications** | **10** | | Strategies to address the identified opportunities for improvement<br>Personal Leadership Profile and Organizational Culture and Climate Alignment |
| **Conclusion** | **10** | | Broadly address the what has been accomplished in the paper<br>Benefits of the completing the assignment |
| Writing conventions, format, and reference citations | **10** | | **Writing is clear concise without grammatical and spelling errors. All references are correctly cited (if applicable) and written.** |
| | | | **A quality assignment will meet or exceed all of the above requirements.** |

NR 534 Week 5: Assignment: Culture and Climate 02_21_19nhs

1

**Week5Assessment.docx**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/week5assessment-docx-10311557)

– 1
– 2

November 5, 2026
[Solved] 507-WK3: D

✓ Verified Academic Solution Available

Executive Solution Overview

In-depth study guidance and analytical solution covering 507-WK3: D.

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

Full assignment prompt and step-by-step guidance are included in the downloadable solution file.

November 5, 2026
[Solved] Create a discussion using APA 7 format, scholarly references no older than 5 years. No plagiarism and NO AI use

✓ Verified Academic Solution Available

Executive Solution Overview

Formulate and refine clinical research questions (PICOT) relevant to advanced nursing practice based on organizational needs assessment results. ### **Participation Requirements** The student must answer the graded discussion with a substantive reply to the graded discussion question(s)/topic(s) pos…

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

Formulate and refine clinical research questions (PICOT) relevant to advanced nursing practice based on organizational needs assessment results.
### **Participation Requirements**
The student must answer the graded discussion with a substantive reply to the graded discussion question(s)/topic(s) posted by the course instructor by Thursday, 11:59 p.m. Eastern Time. Two scholarly sources references are required unless stated otherwise by your professor.
Remember that a new discussion rubric was approved by the professors, committee members, and a majority of the students. Please review the rubric before posting to ensure a maximum of points.
Here are the categories of the new discussion rubric:
**Initial Post** relevance to the topic of discussion, applicability, and insight. (20%)
**Quality of Written Communication** Appropriateness of audience and words choice is specific, purposeful, dynamic, and varied. Grammar, spelling, punctuation. (20%)
**Inclusion of DNP essentials explored in the discussion as well as the role-specific competencies as applicable.**(10%)
**Rigor, currency, and relevance of the scholarly references.** (Use articles that are below 5 years). (20%)
**Peer & Professor Responses.** The number of responses, quality of response posts. (20%)
**Timeliness of the initial post and the answers to the peers. (10%)**

November 5, 2026
[Solved] Nursing

✓ Verified Academic Solution Available

Executive Solution Overview

In-depth study guidance and analytical solution covering Nursing.

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

Full assignment prompt and step-by-step guidance are included in the downloadable solution file.

November 5, 2026
[Solved] Lesson 5

✓ Verified Academic Solution Available

Executive Solution Overview

1. Perform Self-Meditation for six (6) days. 1. Monitor and record your heart rate before and after each meditation session. 2. Then, video record yourself performing the self-meditation session, and attach to this post. 2. After you have experienced practicing meditation, report on the following: 1…

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

1. Perform Self-Meditation for six (6) days.
1. Monitor and record your heart rate before and after each meditation session.
2. Then, video record yourself performing the self-meditation session, and attach to this post.
2. After you have experienced practicing meditation, report on the following:
1. How did you feel about this assignment?
– Were you comfortable or not performing the task on meditation? Explain why or why not.
2. Describe the health benefits and different types of meditation therapies available?
3. Describe the effects of meditation throughout your day-to-day activities and work.
4. Do you believe mediation is a useful alternative and complimentary alternative to healthcare? Explain why or why not.
5. Would you continue to use meditation?
3. Find evidenced-based research article on meditation and attach to this post
4. Remember to include your heart rate tracking before and after each meditation section to this post.
5. Post must be 150-200 words.

November 5, 2026
[Solved] Module 5

✓ Verified Academic Solution Available

Executive Solution Overview

**Scenario** – Your hospital has recently revised its CQI vision and aims based on the work done on the Quality Chasm series. As nurse manager in an ED (Emergency department) you need to take this information and make it “real” for staff in the ED. You and the medical director will present this inf…

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

**Scenario** – Your hospital has recently revised its CQI vision and aims based on the work done on the Quality Chasm series. As nurse manager in an ED (Emergency department) you need to take this information and make it “real” for staff in the ED. You and the medical director will present this information to the staff, but you need to figure out how it applies to daily work and how to engage staff. You both agree that the staff will not appreciate the “words” on the it unless you can attach their meaning to their daily work.
**Instructions:**
1. Read the scenario above and answer the following questions:
1. What information would you use as your base to discuss the vision and the aims?
2. How would you then apply this information to the ED and daily work done by staff?
3. Would benchmarked data be of any use in this scenario to the committee?
2. Your post should:
– Answer the questions as thoroughly and concisely as possible.
– Be sure to reference any works that you utilize in answering the questions
– Be sure that references are in [APALinks to an external site.](https://libraryguides.mdc.edu/ld.php?content_id=52531811) format.

November 5, 2026
[Solved] Module 6

✓ Verified Academic Solution Available

Executive Solution Overview

**Scenario** – You are working in a hospital, and a group of nurses have become vocal about the working conditions. The nurses are from different units in the hospital, and they are upset about the nurse:patient ratio, the mandatory meetings they are required to attend and not get paid, the skipped…

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

**Scenario** – You are working in a hospital, and a group of nurses have become vocal about the working conditions. The nurses are from different units in the hospital, and they are upset about the nurse:patient ratio, the mandatory meetings they are required to attend and not get paid, the skipped meals because there was no one to watch their patients if they were to leave, and, the list goes on. Part of the group wants to look into pursuing this through legal channels. You are part of a group that believes that the Administration should be given an opportunity to correct the situation by negotiating with the nurses.
The problem is magnified by the conflict between the groups of nurses, and it is hard to show a unified front when the nurses are arguing with each other. You want to address the whole group of nurses, and you are trying to put together a speech that will unite the nurses.
**Instructions:**
1. Read the scenario above and answer the following questions:
1. What ideas do you have about a message to all the nurses?
2. What lessons about conflict have you learned that you can apply to this situation?
3. What direction will you decide to lead this group?
2. Your post should:
– Answer the questions as thoroughly and concisely as possible.
– Be sure to reference any works that you utilize in answering the questions
– Be sure that references are in [APALinks to an external site.](https://libraryguides.mdc.edu/ld.php?content_id=52531811) format.

November 5, 2026
[Solved] Mr week 5 soap black male type 2 diabetes

✓ Verified Academic Solution Available

Executive Solution Overview

Mr week 5 soAp note black male type 2 diabetes – ## AGPCSOAPNoteAssignmentInstructions.pdf **## AGPCSOAPNoteAssignmentInstructions.pdf** 1 SOAP Note Assignment Instructions Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the temp…

Instant Solution Download
$6.99

Immediate access to the full model answer, formatted citations, and rubric breakdown.

Need a Fresh Custom Paper?

Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →

Assignment Prompt & Instructions

Mr week 5 soAp note black male type 2 diabetes

– ## AGPCSOAPNoteAssignmentInstructions.pdf

**## AGPCSOAPNoteAssignmentInstructions.pdf**

1

SOAP Note Assignment Instructions

Consider constructing a Word document ‘SOAP note template’ and use it to assemble your
note. By doing this you can use the template for efficiently constructing your SOAP notes such
that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty
person requests to see your SOAP note template you will be required to send it to them for
review.

Sections of the SOAP note should be addressed if they are pertinent to the presenting chief
complaint.

Typhon Encounter #:

Type of Note: Focused or Comprehensive

Subjective (S):

CC: chief complaint – What are they being seen for? This is the reason that the patient sought
care, stated in their own words/words of their caregiver, or paraphrased.

HPI: Who is the historian? Is the historian reliable? History of Present Illness – use the “OLDCART”
approach for collecting data and documenting findings. [O=onset, L=location, D=duration,
C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment,
S=summary]

Past medical history (PMH) – This should include illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history that is pertinent to the visit. Include dates if possible.

Reproductive history: GTPAL, STIs, prenatal care, LMP, contraceptive methods, sexual and
menstrual history. Include dates if possible.

Allergies: State the offending medication/food and the reactions.

Medications: Names, dosages, routes, frequency, and indications.

Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV
risk, sexually active, caffeine, work, and other stressors. Cultural and spiritual beliefs that
impact health and illness. Financial resources.

Family history: Use terms like maternal, paternal and the diseases and the ages they were
deceased or diagnosed if known.

Health Maintenance/Promotion – Required for all SOAP notes: Immunizations, exercise, diet,
screening, etc. Remember to use the United States Clinical Preventative Services Task Force
(USPSTF) guidelines for age-appropriate indicators, Healthy People 2030, and Centers for
Disease Control and Prevention (CDC). This should reflect patient’s current recommendations.
Up to date on health maintenance/promotion will NOT be accepted. Requires references.

Review of systems (ROS) –

• [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when
conducting your ROS to make sure you have not missed any important symptoms,

2

particularly in areas that you have not already thoroughly explored while discussing the
history of present illness.]

You would also want to include any pertinent negatives or positives that would help with your
differential diagnosis. For acute episodic or follow-up visits (focused note) you may be omitting
certain areas such as GYN, Rectal, GI/Abd, etc. As opposed to a comprehensive visit which
would address each system.

Perform either a focused or comprehensive ROS based on the visit type.

General: May include if patient has had a fever, chills, fatigue, malaise, etc.

Skin:

HEENT: head, eyes, ears, nose, and throat

Neck:

Breast:

CV: cardiovascular

Resp: respiratory

GI: gastrointestinal

GYN: gynecologic

GU: genito-urinary

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological

Endo: endocrine

Psych:

Objective (O):

Physical exam (PE) –
• [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when

determining what physical assessments, you want to include to further explore what you
have learned from your subjective data collection]

Perform either a focused or comprehensive exam based on the visit type.

This area should confirm your findings related to the diagnosis. For acute episodic or follow-up
visits (focused) you may be omitting certain areas such as GYN, Rectal, Abd, etc. While a
comprehensive visit will exam each area.

Ensure that you include appropriate male and female specific physical assessments when
applicable to the encounter. Your physical exam information should be organized using the

3

same body system format as the ROS section. Appropriate medical terminology describing the
objective examination is mandatory.
Gen: general statement of appearance if there is any acute distress.

VS: vital signs, height and weight, BMI

Skin:

HEENT: head, eyes, ears, nose, and throat

Neck:

Breast:

CV: cardiovascular

Resp: respiratory

GI: gastrointestinal

GU: genito-urinary

Gyn: gynecologic

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological

Endo: endocrine

Psych:

Diagnostic Tests: This area is for tests that were completed during the patient’s appointment
that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).

Assessment (A):
This section should be a write-up utilizing your clinical decision-making with your
diagnosis/diagnoses being supported by your ‘S’ data set and the ‘O’ data set. Pertinent
positives and negatives must be found in the write-up. References required.

Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each
diagnosis.

Remember to include the appropriate ICD-10 code for each diagnosis.

A statement of current condition and all other chronic illnesses that were addressed during the
visit must be included (i.e., HTN-well managed on medication).

Plan (P):

Your plan should be supported by evidence-based guidelines with appropriate citations utilizing
APA formatting. Your evidence-based plan may be deviated from your preceptor’s plan. Be sure
to comment if there is a deviation in standard of care.

4

Document individual plans directly after each corresponding assessment (i.e., Diagnosis #1
found in the assessment should correlate with Plan #1). Address the following aspects (it should
be separated out as listed below):

Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter
that you plan to review/evaluate relative to your work up for the patient’s chief complaint.
Therapeutic: changes in meds, skin care, counseling, include full prescribing information for
any pharmacologic interventions including the name of the medication, dose, route,
quantity, and number of refills for any new or refilled medications.

Educational: information clients need in order to address their health problems including the
diagnosis itself, education on diagnostics, and therapies. Include follow-up care. Anticipatory
guidance and counseling.

Consultation/Collaboration: referrals or consult while in clinic with another provider. If no
referral made was there a possible referral you could make and why? Advance care planning.

CPT:

References
Reference should support your patient’s management plan, including evidence-based practice,
and utilize APA formatting.

**## AGPCSOAPNoteAssignmentInstructions.pdf**

1

SOAP Note Assignment Instructions

Consider constructing a Word document ‘SOAP note template’ and use it to assemble your
note. By doing this you can use the template for efficiently constructing your SOAP notes such
that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty
person requests to see your SOAP note template you will be required to send it to them for
review.

Sections of the SOAP note should be addressed if they are pertinent to the presenting chief
complaint.

Typhon Encounter #:

Type of Note: Focused or Comprehensive

Subjective (S):

CC: chief complaint – What are they being seen for? This is the reason that the patient sought
care, stated in their own words/words of their caregiver, or paraphrased.

HPI: Who is the historian? Is the historian reliable? History of Present Illness – use the “OLDCART”
approach for collecting data and documenting findings. [O=onset, L=location, D=duration,
C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment,
S=summary]

Past medical history (PMH) – This should include illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history that is pertinent to the visit. Include dates if possible.

Reproductive history: GTPAL, STIs, prenatal care, LMP, contraceptive methods, sexual and
menstrual history. Include dates if possible.

Allergies: State the offending medication/food and the reactions.

Medications: Names, dosages, routes, frequency, and indications.

Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV
risk, sexually active, caffeine, work, and other stressors. Cultural and spiritual beliefs that
impact health and illness. Financial resources.

Family history: Use terms like maternal, paternal and the diseases and the ages they were
deceased or diagnosed if known.

Health Maintenance/Promotion – Required for all SOAP notes: Immunizations, exercise, diet,
screening, etc. Remember to use the United States Clinical Preventative Services Task Force
(USPSTF) guidelines for age-appropriate indicators, Healthy People 2030, and Centers for
Disease Control and Prevention (CDC). This should reflect patient’s current recommendations.
Up to date on health maintenance/promotion will NOT be accepted. Requires references.

Review of systems (ROS) –

• [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when
conducting your ROS to make sure you have not missed any important symptoms,

2

particularly in areas that you have not already thoroughly explored while discussing the
history of present illness.]

You would also want to include any pertinent negatives or positives that would help with your
differential diagnosis. For acute episodic or follow-up visits (focused note) you may be omitting
certain areas such as GYN, Rectal, GI/Abd, etc. As opposed to a comprehensive visit which
would address each system.

Perform either a focused or comprehensive ROS based on the visit type.

General: May include if patient has had a fever, chills, fatigue, malaise, etc.

Skin:

HEENT: head, eyes, ears, nose, and throat

Neck:

Breast:

CV: cardiovascular

Resp: respiratory

GI: gastrointestinal

GYN: gynecologic

GU: genito-urinary

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological

Endo: endocrine

Psych:

Objective (O):

Physical exam (PE) –
• [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when

determining what physical assessments, you want to include to further explore what you
have learned from your subjective data collection]

Perform either a focused or comprehensive exam based on the visit type.

This area should confirm your findings related to the diagnosis. For acute episodic or follow-up
visits (focused) you may be omitting certain areas such as GYN, Rectal, Abd, etc. While a
comprehensive visit will exam each area.

Ensure that you include appropriate male and female specific physical assessments when
applicable to the encounter. Your physical exam information should be organized using the

3

same body system format as the ROS section. Appropriate medical terminology describing the
objective examination is mandatory.
Gen: general statement of appearance if there is any acute distress.

VS: vital signs, height and weight, BMI

Skin:

HEENT: head, eyes, ears, nose, and throat

Neck:

Breast:

CV: cardiovascular

Resp: respiratory

GI: gastrointestinal

GU: genito-urinary

Gyn: gynecologic

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological

Endo: endocrine

Psych:

Diagnostic Tests: This area is for tests that were completed during the patient’s appointment
that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).

Assessment (A):
This section should be a write-up utilizing your clinical decision-making with your
diagnosis/diagnoses being supported by your ‘S’ data set and the ‘O’ data set. Pertinent
positives and negatives must be found in the write-up. References required.

Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each
diagnosis.

Remember to include the appropriate ICD-10 code for each diagnosis.

A statement of current condition and all other chronic illnesses that were addressed during the
visit must be included (i.e., HTN-well managed on medication).

Plan (P):

Your plan should be supported by evidence-based guidelines with appropriate citations utilizing
APA formatting. Your evidence-based plan may be deviated from your preceptor’s plan. Be sure
to comment if there is a deviation in standard of care.

4

Document individual plans directly after each corresponding assessment (i.e., Diagnosis #1
found in the assessment should correlate with Plan #1). Address the following aspects (it should
be separated out as listed below):

Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter
that you plan to review/evaluate relative to your work up for the patient’s chief complaint.
Therapeutic: changes in meds, skin care, counseling, include full prescribing information for
any pharmacologic interventions including the name of the medication, dose, route,
quantity, and number of refills for any new or refilled medications.

Educational: information clients need in order to address their health problems including the
diagnosis itself, education on diagnostics, and therapies. Include follow-up care. Anticipatory
guidance and counseling.

Consultation/Collaboration: referrals or consult while in clinic with another provider. If no
referral made was there a possible referral you could make and why? Advance care planning.

CPT:

References
Reference should support your patient’s management plan, including evidence-based practice,
and utilize APA formatting.

November 5, 2026