Case Study: A 17-Year-Old Female Presented with Alcohol and Nicotine Abuse
Discipline: Nursing
Type of Paper: Coursework
Academic Level: Undergrad. (yrs 3-4)
Paper Format: APA
Question
SOAP Note Assignment
This
SOAP Note should be written based on a 17 year old adolescent patient with
alcohol and nicotine abuse.
Overview
PMHNPs must document information to substantiate
assessments, diagnoses, and plans of care. This facilitates safe patient care
and appropriate transition management. In this assignment, you will create a
SOAP note and discuss what you learned through a specific patient encounter.
Do not include any identifying patient information on your
assignment.
Purpose
The purpose of this assignment is to facilitate the
learner’s ability to create a comprehensive SOAP note.
Assignment outcome
At the conclusion of this assignment, the learner will be
able to:
· Present
a comprehensive SOAP note regarding a specific patient encounter.
· Identify
a particular piece of learning that took place via this specific patient
encounter.
Directions
Select a patient encounter in which you learned something
new. Create a fully formed SOAP note regarding this patient encounter. Present
a comprehensive SOAP note regarding a specific patient encounter with emphasis
on a fully constructed plan of care including pharmacologic, therapeutic, and
nonpharmacologic interventions for an adolescent with substance misuse.
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Soap Note Virtual Case Submission Rubric |
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Criteria |
20 Points |
19 Points |
18 Points |
0 Points |
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Subjective |
Communicates clear & precise assessment data
supported with subjective findings. This should include but not limited to
biological, psychological, sociocultural, spiritual, ethnic, and family
factors. |
Communicates an assessment but may be
missing 1-2 important piece of data |
Communicates a brief & vague assessment
while missing key important details of the assessment data |
No paper submitted or substantial content
missing |
/20 |
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Objective |
Communicates a clear & precise assessment
data supported with objective findings. This should include but not limited to Mental
Status Exam, biological, psychological, sociocultural, spiritual, ethnic, and
family factors. |
Communicates an assessment but may be
missing 1-2 important piece of data |
Communicates a brief & vague assessment
while missing key important details of the assessment data |
No paper submitted or substantial content
missing |
/20 |
|
Assessment |
Thoroughly describes all relevant differential
diagnoses and the actual DSM-V diagnosis with ICD 10 codes. |
Describes differential diagnoses but omits
one that should be considered |
Describes differential diagnoses but omits
more than one that should be considered |
No paper submitted or content missing |
/20 |
|
Plan |
Develops and provides a clearly written
treatment plan, including relevant health promotion and patient education
information. Clearly defines and delineates the levels of evidence that
support the treatment plan. |
Develops a clear set of written orders but
omits an important order for the diagnosis or outdated approach not supported
by evidence. Covers educational topics and health promotion, but no plan is
developed. |
Develops and provides a brief set of orders
for the treatment plan with more than one omission and lacks evidential
support. Health promotion and patient education are substantially lacking or
not covered. |
No paper submitted or content missing |
/20 |
|
Criteria |
10 Points |
8 Points |
6 Points |
0 Points |
/10 |
|
Grammar, spelling, and punctuation |
There are no errors in grammar, spelling, and
punctuation |
There are a few minor errors in grammar,
spelling, and punctuation that do not detract from the meaning |
There are multiple errors in grammar,
spelling, and punctuation that detract from the meaning |
There are major errors in grammar, spelling,
and punctuation that do not reflect scholarly writing |
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APA and references |
The paper meets APA format guidelines and/or all
references are peer reviewed, relevant, scholarly and contemporary, up to 5
years. |
There are minor APA format errors and/or
references meet two requirements of relevant, scholarly or contemporary, up
to 5 years. |
There are multiple errors in format and/or
references meet one requirement of relevant, scholarly or contemporary |
There are significant errors in format
and/or references meet one requirement of relevant, scholarly or contemporary |
/10 |
