Assignment: Genitourinary clinical case
Assignment: Genitourinary clinical case
NSG 6001 Week 4 SOAP Note Assignment
Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
Download the access codes.
Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.
Format
Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be no longer than 3-4 pages excluding the title and the references and in 12pt font.
Patient Setting:
28-year-old female presents to the clinic with a 2 day history of frequency, burning and pain upon
urination; increased lower abdominal pain and vaginal discharge over the past week.
HPI
Complains of urinary symptoms similar to those of previous urinary tract infections (UTIs) which started
approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown fouls
smelling discharge after having unprotected intercourse with her former boyfriend.
PMH
Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Past Surgical History
Tubal ligation 2 years ago.
Family/Social History
Family: Single; history of multiple male sexual partners; currently lives with new boyfriend and 3
children.
Social: Denies smoking, alcohol and drug use.
Medication History
None
Allergy: Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash
ROS
Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.
Physical exam
BP 100/80,
HR 80,
RR 16,
T 99.7 F,
Wt 120,
Ht 5’ 0”
Gen: Female in moderate distress.
HEENT: WNL.
Cardio: Regularrate and rhythm normal S1 and S2.
Chest: WNL.
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.
EXT: WNL.
NEURO: WNL.
Laboratory and Diagnostic Testing
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10-
15, RBC 0-1
Urine gram stain – Gram negative rods
Vaginal discharge culture: Gramnegative diplococci, Neisseria gonorrhoeae, sensitivities pending
Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative
ASSIGNMENT RUBRIC: Assignment: Genitourinary clinical case
“CC”, HPI :OPQRST IF f/u: health status since last visit, response to therapies. PMH, PSH, FH, ROS complete
Minimum of 3 differentials supported by S + O data Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Complete physical exam with critical elements related to subjective data
Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/
Criteria
NOT ACCEPTABLE
0 points
NEEDS IMPROVEMENT (F through C Range)
19 points
COMPETENT (B Range)
22 points
EXCELLENT (A Range)
25 points
Criterion Score
“CC”, HPI :OPQRST IF f/u: health status since last visit, response to therapies. PMH, PSH, FH, ROS complete
Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.
Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided.
Well organized; partial but accurate summary of pertinent information (>80%).
Complete and concise summary of pertinent information.
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Minimum of 3 differentials supported by S + O data Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Less than 50% of diagnoses are listed; or main diagnosis missed;or differential diagnosis not prioritized and/or identified nonexistent problems.
Some diagnoses are identified (50%-80%); incomplete or inappropriate diagnosis prioritization; includes nonexistent diagnosis or extraneous information included.
Most diagnosis are identified and rationally prioritized, including the “main” diagnosis for the case (>80%).
Complete differential diagnosis generated and rationally prioritized; no extraneous information or issues listed.
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This table lists criteria and criteria group name in the first column. The first row lists level names and includes scores if the rubric uses a numeric scoring method. Assignment: Genitourinary clinical case
Criteria
NOT ACCEPTABLE
0 points
NEEDS IMPROVEMENT (F through C Range)
23 points
COMPETENT (B Range)
26 points
EXCELLENT (A Range)
30 points
Criterion Score
Complete physical exam with critical elements related to subjective data
Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.
Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided.
Partial but accurate summary of pertinent information (>80%).
Complete and concise summary of pertinent information. Assignment: Genitourinary clinical case
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This table lists criteria and criteria group name in the first column. The first row lists level names and includes scores if the rubric uses a numeric scoring method.
Criteria
NOT ACCEPTABLE
0 points
NEEDS IMPROVEMENT (F through C Range)
35 points
COMPETENT (B Range)
40 points
EXCELLENT (A Range)
45 points
Criterion Score
Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/
| Less than 50% of diagnosis have an appropriate and complete treatment plan. |
Less than 50% of diagnosis includeappropriate counseling, monitoring, referral and/or follow-up plan.
| Partially complete and/or inappropriate for a few identified diagnosis (50%-80%); information other than “P” provided. |
Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).
| Mostly complete and appropriate for each identified problem (>80%). |
Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.
| Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem. |
Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.
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Rubric Total ScoreTotal
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