Assignment Prompt & Instructions
– ## EpisodicVisit2.docx
**## EpisodicVisit2.docx**
Episodic Visit: Dermatology Focused Note
Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will work with an adolescent patient that you examined during the last 3 weeks and complete a Focused Note Template in which you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. In this week’s Learning Resources, please refer to the Focused Note resources for guidance on writing Focused Notes.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and PDFimages of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
[**WEEKLY RESOURCES**](https://waldenu.instructure.com/courses/172095/modules/items/6936799)
**To prepare:**
· Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
· Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
· Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
**Assignment**
· Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
· Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
**Note**: Your Focused Note Assignment must be signed by Day 7 of Week 6.
By Day 7
Submit your Focused Note Assignment. (Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6.)
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.
1. To submit your completed assignment, save your Assignment as
**WK6Assgn2+last name+first initial.**
2. Then, click on
**Start Assignment** near the top of the page.
3. Next, click on
**Upload File** and select
**Submit Assignment** for review.
Rubric
**PRAC_6541_Week6_Assignment2_Rubric**
| | | |
| — | — | — |
| PRAC_6541_Week6_Assignment2_Rubric |
| **Criteria** | **Ratings** | **Pts** |
| This criterion is linked to a Learning OutcomeOrganization of Write-up | **10 to >6.0 ptsExcellent** All information organized in logical sequence; follows acceptable format and utilizes expected headings.<br> <br>**6 to >3.0 ptsGood** Information generally organized in logical sequence; follows acceptable format and utilizes expected headings.<br> <br>**3 to >0.0 ptsFair** Errors in format; information intermittently organized. Headings are used some of the time.<br> <br>**0 ptsPoor** Errors in format; information disorganized. Headings are not used appropriately. | 10 pts |
| This criterion is linked to a Learning OutcomeThoroughness of History | **20 to >15.0 ptsExcellent** Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information.<br> <br>**15 to >11.0 ptsGood** Documents most pertinent examination components.<br> <br>**11 to >7.0 ptsFair** Documents some pertinent examination components.<br> <br>**7 to >0 ptsPoor** Physical examination cursory; misses several pertinent components. | 20 pts |
| This criterion is linked to a Learning OutcomeHistory of Present Illness | **10 to >6.0 ptsExcellent** Thoroughly documents all 8 aspects of HPI and pertinent other data relevant to chief complaint. Includes critical as well as supportive information.<br> <br>**6 to >4.0 ptsGood** Documents at least 6 aspects of the HPI and pertinent other data relevant to chief complaint. Includes critical information.<br> <br>**4 to >2.0 ptsFair** Documents at least 4 aspects of HPI and some data pertinent to chief complaint. Lacks some critical information or rambling in history.<br> <br>**2 to >0 ptsPoor** Missing many aspects of HPI and pertinent data. Critical information missing. | 10 pts |
| This criterion is linked to a Learning OutcomeThoroughness of Physical Exam | **10 to >7.0 ptsExcellent** Thoroughly documents all pertinent examination components for type of note.<br> <br>**7 to >4.0 ptsGood** Documents most pertinent examination components.<br> <br>**4 to >2.0 ptsFair** Documents some pertinent examination components.<br> <br>**2 to >0 ptsPoor** Physical examination cursory; misses several pertinent components. | 10 pts |
| This criterion is linked to a Learning OutcomeDiagnostic Reasoning | **10 to >7.0 ptsExcellent** Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests.<br> <br>**7 to >4.0 ptsGood** Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.<br> <br>**4 to >2.0 ptsFair** Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests.<br> <br>**2 to >0 ptsPoor** Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests. | 10 pts |
| This criterion is linked to a Learning OutcomeTreatment Plan/Patient Education | **20 to >15.0 ptsExcellent** Treatment plan addresses all issues raised by diagnoses, excellent insight into patient’s needs. Medications prescribed are appropriate and full prescription is included. Evidence based decisions. Cost effective treatment.<br> <br>**15 to >10.0 ptsGood** Treatment plan addresses most issues raised by diagnoses. Medications prescribed are appropriate but include 1 or 2 error in writing prescription.<br> <br>**10 to >5.0 ptsFair** Treatment plan fails to address most issues raised by diagnoses. Medications are inappropriate or include 3 or more errors in writing prescription.<br> <br>**5 to >0 ptsPoor** Minimal treatment plan addressed. Medications are inappropriate or poorly written prescription. | 20 pts |
| This criterion is linked to a Learning OutcomePatient Education / Follow Up / Reflection | **10 to >8.0 ptsExcellent** Patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Follow up plan in appropriate and reflects acuity of illness. Reflection is thoughtful and in depth.<br> <br>**8 to >5.0 ptsGood** Patient education addresses most issues raised by diagnoses. Follow up plan is appropriate but lacks specifics Reflection is thoughtful and in depth.<br> <br>**5 to >3.0 ptsFair** Patient education fails to address most issues raised by diagnoses. Follow up plan is lacking specifics or is inappropriate for patient acuity. Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.<br> <br>**3 to >0 ptsPoor** Minimal patient education addressed. Follow up plan is inappropriate Reflection is absent. | 10 pts |
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation. Professional language utilized | **5 ptsExcellent** Uses correct grammar, spelling, and punctuation with no errors. Professional language utilized.<br> <br>**4 ptsGood** Contains a few (1-2) grammar, spelling, and punctuation errors. Contains a few errors (1 or 2) in professional language use.<br> <br>**2 ptsFair** Contains several (3-4) grammar, spelling, and punctuation errors. Contains several errors (3 -4) in professional language use.<br> <br>**0 ptsPoor** Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Contains many errors in professional language use. | 5 pts |
| This criterion is linked to a Learning OutcomeScholarly References and Clinical Practice Guidelines. The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Clinical practice guidelines are included if applicable. | **5 ptsExcellent** Contains parenthetical/in-text citations and at least 3 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.<br> <br>**4 ptsGood** Contains parenthetical/in-text citations and at least 2 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.<br> <br>**2 ptsFair** Contains parenthetical/in-text citations and at least 1 evidenced based reference less than 5 years old is listed. Clinical practice guidelines are not cited if applicable.<br> <br>**0 ptsPoor** Contains no parenthetical/in-text citations and 0 evidenced based references listed. Clinical practice guidelines are not cited if applicable. | 5 pts |
Total Points: 100
**## EpisodicVisit2.docx**
Episodic Visit: Dermatology Focused Note
Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will work with an adolescent patient that you examined during the last 3 weeks and complete a Focused Note Template in which you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. In this week’s Learning Resources, please refer to the Focused Note resources for guidance on writing Focused Notes.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and PDFimages of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
[**WEEKLY RESOURCES**](https://waldenu.instructure.com/courses/172095/modules/items/6936799)
**To prepare:**
· Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
· Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
· Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
**Assignment**
· Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
· Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
**Note**: Your Focused Note Assignment must be signed by Day 7 of Week 6.
By Day 7
Submit your Focused Note Assignment. (Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6.)
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.
1. To submit your completed assignment, save your Assignment as
**WK6Assgn2+last name+first initial.**
2. Then, click on
**Start Assignment** near the top of the page.
3. Next, click on
**Upload File** and select
**Submit Assignment** for review.
Rubric
**PRAC_6541_Week6_Assignment2_Rubric**
| | | |
| — | — | — |
| PRAC_6541_Week6_Assignment2_Rubric |
| **Criteria** | **Ratings** | **Pts** |
| This criterion is linked to a Learning OutcomeOrganization of Write-up | **10 to >6.0 ptsExcellent** All information organized in logical sequence; follows acceptable format and utilizes expected headings.<br> <br>**6 to >3.0 ptsGood** Information generally organized in logical sequence; follows acceptable format and utilizes expected headings.<br> <br>**3 to >0.0 ptsFair** Errors in format; information intermittently organized. Headings are used some of the time.<br> <br>**0 ptsPoor** Errors in format; information disorganized. Headings are not used appropriately. | 10 pts |
| This criterion is linked to a Learning OutcomeThoroughness of History | **20 to >15.0 ptsExcellent** Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information.<br> <br>**15 to >11.0 ptsGood** Documents most pertinent examination components.<br> <br>**11 to >7.0 ptsFair** Documents some pertinent examination components.<br> <br>**7 to >0 ptsPoor** Physical examination cursory; misses several pertinent components. | 20 pts |
| This criterion is linked to a Learning OutcomeHistory of Present Illness | **10 to >6.0 ptsExcellent** Thoroughly documents all 8 aspects of HPI and pertinent other data relevant to chief complaint. Includes critical as well as supportive information.<br> <br>**6 to >4.0 ptsGood** Documents at least 6 aspects of the HPI and pertinent other data relevant to chief complaint. Includes critical information.<br> <br>**4 to >2.0 ptsFair** Documents at least 4 aspects of HPI and some data pertinent to chief complaint. Lacks some critical information or rambling in history.<br> <br>**2 to >0 ptsPoor** Missing many aspects of HPI and pertinent data. Critical information missing. | 10 pts |
| This criterion is linked to a Learning OutcomeThoroughness of Physical Exam | **10 to >7.0 ptsExcellent** Thoroughly documents all pertinent examination components for type of note.<br> <br>**7 to >4.0 ptsGood** Documents most pertinent examination components.<br> <br>**4 to >2.0 ptsFair** Documents some pertinent examination components.<br> <br>**2 to >0 ptsPoor** Physical examination cursory; misses several pertinent components. | 10 pts |
| This criterion is linked to a Learning OutcomeDiagnostic Reasoning | **10 to >7.0 ptsExcellent** Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests.<br> <br>**7 to >4.0 ptsGood** Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.<br> <br>**4 to >2.0 ptsFair** Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests.<br> <br>**2 to >0 ptsPoor** Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests. | 10 pts |
| This criterion is linked to a Learning OutcomeTreatment Plan/Patient Education | **20 to >15.0 ptsExcellent** Treatment plan addresses all issues raised by diagnoses, excellent insight into patient’s needs. Medications prescribed are appropriate and full prescription is included. Evidence based decisions. Cost effective treatment.<br> <br>**15 to >10.0 ptsGood** Treatment plan addresses most issues raised by diagnoses. Medications prescribed are appropriate but include 1 or 2 error in writing prescription.<br> <br>**10 to >5.0 ptsFair** Treatment plan fails to address most issues raised by diagnoses. Medications are inappropriate or include 3 or more errors in writing prescription.<br> <br>**5 to >0 ptsPoor** Minimal treatment plan addressed. Medications are inappropriate or poorly written prescription. | 20 pts |
| This criterion is linked to a Learning OutcomePatient Education / Follow Up / Reflection | **10 to >8.0 ptsExcellent** Patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Follow up plan in appropriate and reflects acuity of illness. Reflection is thoughtful and in depth.<br> <br>**8 to >5.0 ptsGood** Patient education addresses most issues raised by diagnoses. Follow up plan is appropriate but lacks specifics Reflection is thoughtful and in depth.<br> <br>**5 to >3.0 ptsFair** Patient education fails to address most issues raised by diagnoses. Follow up plan is lacking specifics or is inappropriate for patient acuity. Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.<br> <br>**3 to >0 ptsPoor** Minimal patient education addressed. Follow up plan is inappropriate Reflection is absent. | 10 pts |
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation. Professional language utilized | **5 ptsExcellent** Uses correct grammar, spelling, and punctuation with no errors. Professional language utilized.<br> <br>**4 ptsGood** Contains a few (1-2) grammar, spelling, and punctuation errors. Contains a few errors (1 or 2) in professional language use.<br> <br>**2 ptsFair** Contains several (3-4) grammar, spelling, and punctuation errors. Contains several errors (3 -4) in professional language use.<br> <br>**0 ptsPoor** Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Contains many errors in professional language use. | 5 pts |
| This criterion is linked to a Learning OutcomeScholarly References and Clinical Practice Guidelines. The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Clinical practice guidelines are included if applicable. | **5 ptsExcellent** Contains parenthetical/in-text citations and at least 3 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.<br> <br>**4 ptsGood** Contains parenthetical/in-text citations and at least 2 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.<br> <br>**2 ptsFair** Contains parenthetical/in-text citations and at least 1 evidenced based reference less than 5 years old is listed. Clinical practice guidelines are not cited if applicable.<br> <br>**0 ptsPoor** Contains no parenthetical/in-text citations and 0 evidenced based references listed. Clinical practice guidelines are not cited if applicable. | 5 pts |
Total Points: 100