NUR 600 Writing a SOAP Note Assignment

NUR 600 Writing a SOAP Note Assignment

NUR 600 Writing a SOAP Note Assignment

Assignment Guidelines

Submit a write-up on a family member or friend who has given you permission. The write-up needs to include thorough Subjective, Objective, Assessment, and Plan documentation. Make sure to provide a complete ROS and a complete head-to-toe assessment (breast and GU systems do not need to be assessed). Please look at your previous system write-ups and recommendations to incorporate into this assignment. Refer to Bickley’s write-ups, especially The Case of Mrs. N. from Chapter 1.

Submission

Submit your assignment and review full grading criteria on the Assignment 11.2: Writing a SOAP Note page.

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Week 11: The Comprehensive Physical Exam (cont.)—Behavior and Mental Health

Welcome to the eleventh week of Advanced Physical Assessment. During this lesson, you will continue to coordinate the comprehensive physical exam. The focus of this week is the behavior and mental status assessment. Please keep in mind that because there is a psychiatric nurse practitioner specialty degree, this unit will provide only a brief overview of the psychiatric assessment, as family nurse practitioners do not typically perform this focused exam in detail. You will look different exam techniques and then practice your exam assessment. You will review proper terminology for identifying and then appropriately documenting those subjective and objective findings. You will also focus on the seven crucial conversations that healthcare providers struggle with.

Review a list of all items due this week in your course syllabus.

Lesson 1: Behavior and Mental Health Status

During this lesson, you will continue to coordinate the comprehensive exam, focus on the behavior and mental status, look at different exam techniques, and review proper terminology for objective findings. Please note that this is just a brief summary of mental and behavioral health. These topics require far more attention from specialists and will only be covered in a general sense in this course.

Learning Outcomes

At the end of this lesson, you will be able to:

Begin the practice of sequencing and coordinating the comprehensive physical exam of the adult patient regarding mental and behavioral health status.

Identify the anatomical landmarks of the human body of mental and behavioral health.

Correlate examination techniques of the patient’s mental and behavioral status using the correct sequence and anatomical landmarks in an adult patient.

Use correct terminology to record objective components of the physical examination findings.

Before attempting to complete your learning activities for this week, review the following learning materials:

Learning Materials

Read the following in your Bates’ Guide to Physical Examination and History Taking textbook:

Chapter 9, “Cognition, Behavior, and Mental Status”

Additional Required Resources:

Also read the following article:

Grenny, J. (2009). Crucial conversations: The most potent force for eliminating disruptive behavior. Critical Care Nursing Quarterly, 32(1), 58–67.

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This reading will help you perform a mental status assessment, recognize pertinent positives and negatives related to that system, and also document appropriately.