1. About Long SOAP note for CHF patient, long (Expanded) SOAP Notes…

1. About Long SOAP note for CHF patient, long (Expanded) SOAP Notes…  1. About Long SOAP note for CHF patient, long (Expanded) SOAP Notes Student: Evaluator: Category Meets Standard POINTS Pathophysiology  2. Briefly discusses the pathophysiological processes pertinent to the client’s specific case. In multiple disease states, an explanation of the effect of one disease process on another must be provided. 10 points possible  3. The rationale for Treatment Plan Justification is provided for clinical decision making regarding the selected management plan. It is the WHY and HOW of the plan of care. DO NOT simply cite protocol texts sources but describe the steps behind the management decisions. Documentation for the plan of care must be provided. Use of research articles, current clinical updates and required texts may be used for resources. List in references at end of document. 20 points possible  4. Application of Advanced Nursing Practice Framework Includes a brief description of how the student integrated their personal practice framework into the client/family encounter. This must be specific to the patient 10 points possible  5. Application of Family Theory Includes a brief discussion of the student’s understanding regarding the use of family systems theory, family developmental theory or other appropriate family-oriented framework used in the client/family encounter. Determining the avenue to explore will depend upon each clinical situation and the student should be looking for subtle clues the client may exhibit. For example 1)Was the family constellation assessed? 2) Was the client’s role within the family system assessed in relation to the presenting complaint? 3) Did the family’s developmental stage influence the care given? 4) Was the referral source chosen based on the impending family crisis? 5) How was the client’s health affected by the ability to care for the other family members? 6) How does the chronic illness of the client affect the family system? 7) Will the change in the client’s behavior occur based upon previous role rigidity in the other family members? 10 points possible  6. Cost Analysis The student must calculate the actual cost of the visit to the client and to the system. The cost of the visit, diagnostic tests ordered, pharmaceuticals prescribed, treatments rendered, etc should be calculated. Furthermore, consideration must be given to payment sources i.e, cash, insurance, pre-authorized services. 10 points possible  7. Ethical Considerations Select an ethical theory and specific principle and analyze the clinical case based upon its parameters. Value conflicts may be identified and options for resolution may be discussed. This should apply specifically to this patient. 10 points possible  8. Cultural Considerations The student identifies specific cultural considerations pertinent to this patient encounter. 10 points possible  9. Self Critique Student answers s What would you do differently in this case? What did you do will? What will you do next time you have a patient like this, i.e, what have you learned in the analysis of this patient’s case? What have you learned about doing the initial SOAP note? 10 points possible  10. Scholarly Writing Document is without grammar, punctuation, and spelling errors. Citations and references are in APA Format 10 points possible  Health Science Science Nursing APN MISC Share EmailCopy link Comments (0)

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