NURS 5323 Week 3 MSN Personal Clinical Objectives Assignment

Overview: From this submission, you need to develop anywhere from 3-4 personal objectives for clinicals that you will work to meet throughout the semester. As you log your clinical hours, you will need to document how those hours helped you to meet one or more of your personal objectives. You will evaluate your progress towards meeting these objectives throughout your clinical rotation. You will share these objectives with your preceptor so that they will know what your goals are.

Instructions: Please use the template below to type in your objectives. You do NOT need a title page or a reference page. Please submit in pdf or word format by the due date indicated on the course schedule.

**Use SMART format when writing your clinical objectives. Try to be as specific as you can be when writing your objectives. Ensure that your goal is measurable. Do not use terms such as “more comfortable” as you often cannot measure this. Your goal should be relevant to your clinical rotation and site and should be attainable. Make sure to include the time frame for achievement. Make sure your objectives are clearly distinct from one another and do not overlap**

Example: By the third week of the clinical rotation, I will be able to independently interpret at least 3 treadmill stress tests without the assistance of my preceptor.

This assignment will help you meet the following: AACN Essentials (2022): Domains 2, 6, 9, 10; AACN MSN Essentials (2011): II, VII, IX; NONPF NP Core and Population-Focused Competencies (2012;2017): Leadership and Independent Practice.

Personal Clinical Objectives Template

Name:

Course Name and Number:

Preceptor’s name:

Agency/Practicum Site:

MSN Personal Clinical Objectives Rubric

Criteria	Meets Expectations	Does not Meet Expectations	No effort
Objective 1	30 points · Objective is in SMART format· Objective is specific and not superficial· Objective is measurable and excludes any goals that cannot be measured· Objective is attainable within the students scope of practice and clinical rotation· Objective is relevant to the clinical rotation and fits within the overall objectives for the clinical rotation· Objectives is defined by time and the time is appropriate for the written objective	15 points · Missing one or more components	0 Points · No effort
Objective 2	30 points · Objective is in SMART format· Objective is specific and not superficial· Objective is measurable and excludes any goals that cannot be measured· Objective is attainable within the students scope of practice and clinical rotation· Objective is relevant to the clinical rotation and fits within the overall objectives for the clinical rotation· Objectives is defined by time and the time is appropriate for the written objective	15 points · Missing one or more components	0 Points · No effort
Objective 3	30 points · Objective is in SMART format· Objective is specific and not superficial· Objective is measurable and excludes any goals that cannot be measured· Objective is attainable within the students scope of practice and clinical rotation· Objective is relevant to the clinical rotation and fits within the overall objectives for the clinical rotation· Objectives is defined by time and the time is appropriate for the written objective	15 points · Missing one or more components	0 Points · No effort
Professionalism	10 Points · Objectives submitted on appropriate template· Less than 2 grammatical or spelling errors· Additional objectives meet all the appropriate criteria	5 Points · Objectives not submitted on appropriate template and/or· More than 2 grammatical or spelling errors· Additional objectives do not meet the appropriate criteria	0 Points · No effort

NURS 5323 Module 4

Readings: Leifer & Fleck: Chapters 5–6

PowerPoints

Attached Files:

o Leifer – Chapter 5 Book Powerpoint (79.324 KB)

o Leifer – Chapter 6 Book Powerpoint (69.646 KB)

Texas Health Steps Modules Week 4

Due Saturday 23:59

Go to https://www.txhealthsteps.com/courses
Complete the required modules:

Genetic Screening, Testing, Treatment and Referral
Preconception Health: Screening and Intervention
Prenatal Health: Screening and Intervention

3. Submit a PDF copy of CE certificate/proof of completion.

NURS 5323 Module 5 Overview

Review as needed

Exam 1 will open on Wednesday at 0000 and close on Saturday at 2359. The exam will not be visible in this Module or your Blackboard calendar until the exam opens.

NURS 5323 Module 6·

Readings: Leifer & Fleck: Chapter 7

PowerPoint

Attached Files:

o Leifer – Chapter 7 Book Powerpoint.pptx (64.229 KB)

Texas Health Steps Modules Week 6

Due Saturday 23:59

Go to https://www.txhealthsteps.com/courses
Complete the required modules:

Critical Congenital Heart Disease
Infant Safe Sleep
Newborn Hearing Screening
Newborn Screening

3. Submit a PDF copy of the CE certificate/proof of completion.

NURS 5323 Module 7

Overview

Readings: Leifer & Fleck: Chapter 7

PowerPoint

Attached Files:

o Leifer – Chapter 7 Book Powerpoint (64.229 KB)

Texas Health Steps Modules Week 7

Due Saturday 23:59

Go to https://www.txhealthsteps.com/courses
Complete the required modules:

XALD: Newborn Screening, Treatment, and Referral
Sickle Cell Disease and Trait
Developmental Surveillance and Screening: Birth through 6 Years

Submit a PDF copy of the CE certificate/proof of completion.

Infant Discussion Board Case Study Discussion

A 6-month-old male infant is brought to your office by his mother for a routine well-child visit. His mother is concerned that he is not yet saying “mama,” because her best friend’s baby said “mama” by age 6 months. Your patient was born via an uncomplicated pregnancy to a 23-year-old G1 P1 mother. He was delivered by a spontaneous vaginal delivery at full term and there were no complications in the neonatal period. You have been following him since his birth.

He has had appropriate immunizations. He had one upper respiratory infection at 5 months that was treated symptomatically. There is no family history of any developmental, hearing, or speech disorders. He has been fed since birth with iron-fortified infant formula. Cereals and other baby foods were added starting at age 4 months. He lives with both parents, neither of whom smokes cigarettes.

On exam, he is a vigorous infant who is at the 50th percentile for length and weight and 75th percentile for head circumference. His physical examination is normal. On developmental examination, he is seen to sit for a short period of time without support, reach out with one hand for your examining light, pick up a Cheerio with a raking grasp and put it in his mouth, and he is noted to babble frequently.

Answer questions 1- 5 using course resources and at least one additional scholarly resource found outside the course resources.

What immunizations would be recommended at this visit?
By what age should an infant say “mama” and “dada”?
What are some milestones to discuss with the parent during this visit?
The child’s mother asks when she can place him in a front-facing car seat. What is your recommendation?
Discuss health maintenance in infancy.

Answer questions 1- 5 using course resources and at least one additional scholarly resource found outside the course resources.

Deliverable Instructions:

You will not be able to see posts until you post yours.
Initial post by Wednesday 23:59.
Replies to peers by Friday 23:59.
Additional replies as appropriate by Saturday 23:59 (closing the loop).
Initial discussion post word count should be no more than 500 words.
Reply posts should be no more than 350 words.
Late posts will incur a 10% penalty per day.
For grading criteria, see Discussion Board Participation Rubric.

MSN Personal Clinical Objectives Update

Overview: From this submission, you need to evaluate your progress towards meeting the objectives you submitted previously. Have you met the objectives? Do you realize the objective is not relevant or unattainable? If you have met the objectives, do you have new ones? Do you need to revise the objectives? Remember, as you log your clinical hours, you will need to document how those hours helped you to meet one or more of your personal clinical objectives.

Instructions: Please use the template below to fill in your updates. Make sure to include your original personal clinical objective created earlier in the semester. Type your updates directly underneath your stated objective. You must address each objective – whether it has been met or your progress towards meeting it. Discuss specific patient cases (1-2 cases) as examples to justify that the objective was met. You do NOT need a title page or a reference page. Please submit in pdf or word format by the due date indicated on the course schedule.

**Use SMART format when writing your clinical objectives. Try to be as specific as you can be when writing your objectives. Ensure that your goal is measurable. Your goal should be relevant to your clinical rotation and site and should be attainable. **

Example: By the end of this clinical rotation, I will be able to independently interpret at least 3 treadmill-stress tests.

I have completed 5 treadmill-stress tests but was only able to interpret 1 without the assistance of my preceptor. My preceptor made plans to give me a few stress EKGs that have been completed for me to practice some more. The clinic does about 4 -5 treadmill stress test per day, so I am confident that I can achieve this goal by the end of my clinical rotation.

Personal Clinical Objectives Update Template

Name:

Course Name and Number:

Preceptor’s name:

Agency/Practicum Site:

Clinical Log for NP Student Clinical Hours and Preceptor Signature

Student Name:

Clinical Site:

Course:

Date	Hours	Total Hours at Site	Preceptor Signature

MSN Clinical Update Assignment Instructions and Rubric

Overview: The purpose of the clinical update assignment is to thoroughly reflect on your time spent during your clinical rotation. This reflection should be consistent and ongoing throughout your clinical rotation. The clinical update assignment allows for you and your clinical faculty/preceptor to address both positive experiences and concerns encountered during the clinical rotation.

In the assignment, the student will reflect on their personal clinical objectives created at the beginning of the semester and evaluate their progress towards achieving the objectives. The Clinical Update helps ensure the student is on track in documenting their clinical hours and clinical case logs in Typhon. The assignment helps to facilitate communication between the student, clinical faculty, and preceptor.

Instructions: The assignment has four components:

1. Grad CPAT Student Reflection Form (Clinical Update #1)

Students will check competencies that have been accomplished thus far in the current clinical rotation. Only mark the actions that apply. Students must make comments under each Domain showing deep reflection on how these competencies have been met or are in progress. You assign a self-score for each Domain.

Scoring Scale: (1) Failing; does not meet standards; requires constant guidance (2) Needs Improvement; requires intensive guidance (3) Satisfactory with direction (4) Meets Expectations with Assistance (5) Exceeds Expectations with Minimal Assistance.

Remember that the quality of your clinical performance as you describe in detail in the “Student Comments” determines your grade. It is not necessary to check all of the actions listed to get higher grades. Grades are determined by the quality of your work and reflections in the “Student Comments” not by the number of items checked. You should provide concrete examples, especially if assigning a score of 1 or 5.

Clinical Update Form (Clinical Update #2)

Students will type answers to prompts directly on the form. Answers should be thorough and show deep reflection of the student’s clinical experience. Each prompt must be addressed.

2. MSN Personal Clinical Objectives Update

Students will use the template provided in the course to provide a thorough evaluation of their progress towards their personal clinical objectives. Student’s original personal clinical objective created earlier in the semester should be included and the student will type updates directly underneath your stated objective. Student will discuss specific patient cases (1-2 cases) as examples to justify that the objective was met. You do NOT need a title page or a reference page.

3. Typhon Update

Student should be logging their patients in Typhon on a frequent and consistent basis. For this update, please submit a graphical spreadsheet showing that case logs and hours for the clinical rotation are up-to-date. An example can be located in the course.

4. Clinical Hours Log

Student is responsible for obtaining preceptor signature at the end of each clinical day. For the update, student will submit the signed clinical hours log. Dates and hours must match the dates and hours in Typhon and the latest clinical schedule submitted in the course.

MSN Clinical Update Assignment Rubric

Criteria	Meets Expectations	Needs Improvement	Does not meet Expectations
Graduate CPAT Self-Reflection Form / Clinical Update Form	40 points · Graduate CPAT Self Reflection Form / Clinical update form submitted on appropriate template· Student answers show thorough reflection and insight into clinical experience/progress· Each prompt is addressed· 0-2 grammatical or spelling errors	20 points · Superficial responses to question prompts· Missing one or more components· More than 3 grammatical or spelling errors	0 Points · Not submitted
Personal Clinical Objectives Update	15 Points · Personal objective update submitted on appropriate template and in appropriate format· Reflections show thorough insight into progress with 1-2 cases as examples for met objectives· 0-2 grammatical or spelling errors	7.5 points · Superficial responses to question prompts· Missing one or more components· More than 3 grammatical or spelling errors	0 Points · Not submitted
Typhon Update	30 points · Typhon log pdf submitted to Blackboard· Case logs are up-to-date· Case logs are in proper format	15 points · Missing one or more components	0 Points · Not submitted
Clinical Hours Log	15 Points · Clinical log accurate with preceptor’s signature· Clinical hours log match the latest submitted clinical schedule and Typhon history	7.5 Points · Clinical log missing dates and/or not signed by preceptor· Clinical hours log does not match submitted clinical schedule and Typhon history	0 Points · No submitted

GRADUATE CLINICAL PERFORMANCE ASSESSMENT TOOL (GCPAT)—

Student Self-Reflection Worksheet: Course NURS ______

Check one of the following: Clinical Mid-point ____ or End of Semester Review _____

Instructions: Only mark the actions that apply. Remember that the quality of your clinical performance as you describe in detail in the “Student Comments” determines your grade. It is not necessary to check all of the actions listed to get higher grades. Grades are determined by the quality of your work and reflections in the “Student Comments” not by the number of items checked.

Role 1 (R1): Provider of Care; Domain 1 (R 1-D1) Knowledge of Nursing PracticeCompetencies: Clinical reasoning and Judgment, Scope of Practice, Standards of Care. NP: Knowledge of Practice	Score
· ____ Assesses environmental and Individual factors to obtain and accurately document relevant health histories and focused assessments for clients of all ages· ____ Performs and accurately documents appropriate comprehensive or focused physical examinations of clients of all ages.· ____ Conducts family assessment· ____ Recognizes & analyzes cues to formulate and refine hypotheses of health needs/concerns to identify health and psychosocial risk factors of clients and families in all stages of the family life cycle.· ____ Distinguishes between normal and abnormal changes with aging· ____ Identifies signs and symptoms of acute and chronic illnesses across the lifespan· ____ Prioritizes health needs and generates planned solutions to meet those needs· ____ Takes action to implement standards of care within scope of practice for APRN’s· ____ Evaluates outcomes of care and revises plan and interventions based on the evaluation data
Student Comments:
Domain 2 (R1-D2): NP: Person-Centered CareCompetencies: Patient Centered Care and Nursing Skills.
· ____ Provides holistic, patient-centered, safe nursing care using systematic processes· ____ Safely performs preventative, restorative, rehabilitative, and supportive interventions including safe client handling and interdisciplinary care measures· ____ Promptly and accurately documents care and client’s response to care· ____ Plans, directs, controls, and evaluates according to the goals established, the setting of the activities, and persons involved.· ____ Considers alternative approaches when faced with a problem to solve· ____ Considers the ethical outcome of actions before they are implemented· ____ Examines all aspects (physical psychosocial, developmental, cultural, and spiritual) of a situation when establishing a goal or making a judgment that will affect others· ____ Uses imagination to generate new ways to solve old and repetitive problems.
Student Comments:
Domain 3 (R1-D3): Population HealthCompetencies: Community Health, Global Health, and Healthcare Delivery System. NP Health Delivery System and Clinical Prevention and Populations Health CompetenciesNP: Population Health
· ____ Assesses environmental, cultural and spiritual relationships that impact quality of life, years of healthy life and health disparities· ____ Analyzes the family and community health factors that affect the person’s health· ____ Adheres to legal and ethical principles, and site policies and procedures· ____ Seeks site resources for providing holistic care
Student Comments:
Role 2 (R2): Member of the Profession. Domain 4 (R2-D4): Scholarship for Nursing PracticeCompetencies: Nursing Research/Evidence –Based Practice and Nursing Science.NP: Practice Scholarship and Translational Science
· ____ Demonstrates knowledge of current literature (particularly research literature) related to clinical practice.· ____ Incorporates information from textbooks and professional journals into the plan of care· ____ Uses research findings as a basis for discussion for actions taken with clients· ____ Uses resources to solve problems when faced with an unfamiliar or new dilemma· ____ Uses standard references to compare expected and achieved outcomes of nursing care and modifies care in response to subtle or overt shifts in client status· ____ Evaluates the credibility of information sources including data accessed on the world wide web
Student Comments:
Domain 9 (R2-D9): ProfessionalismCompetencies: Lifelong Learning and Contributions to the Profession. NP: Professional Acumen
· ____ Demonstrates professional conduct, appearance, and dress· ____ Assumes responsibility for own actions, practice and learning; seeks out and accepts constructive feedback on own performance and improves behaviors· ____ Engages in self-reflection and evaluation to refine practice and improve care· ____ Complies with professional and organizational standards of appearance, demeanor, behavior, and client confidentiality· ____ Seeks guidance and clarification in areas outside of scope and own knowledge and abilities· ____ Demonstrates good professional character· ____ Reports unsafe incidents including near misses· ____ Upholds boundaries of the Nurse-Client Relationship
Student Comments:
Domain 10 (R2-D10): Personal, Professional, and Leadership DevelopmentCompetencies: Innovation, Integration of Resources for Patient Care, Upholds Regulatory and Accreditation Standards, and Guides others for Care CoordinationNP: Personal and Professional Leadership
· ____ Individualizes care based on client’s personal, cultural, and spiritual relationships while maintaining standards of care and APRN scope of practice· ____ Upholds National Patient Safety Goals and other Joint Commission standards· ____ Provides clear directives when delegating activities to others____ Communicates (verbally and in writing) desires, concerns and information in a concise, clear and respectful way to clients, preceptors, staff and faculty
Student Comments:
Role 3 (R3): Patient Safety Advocate. Domain 5 (R3-D5): NP: Quality and Safety.Competency: Quality Improvement, including Patient Safety, Core Measures, and Cultural of Safety.
· ____ Role models and acts as an advocate for client needs, health literacy, healthy lifestyle, and early detections and treatment of diseases, illnesses, mental illnesses and injuries in adults· ____ Provides educational materials that address the language and cultural beliefs of clients; provides anticipatory guidance, teaching, counseling and education for clients and their families· ____ Plan of care is based on Specific, Measurable, Achievable, Realistic, and Timely (SMART) goals· ____ Seeks feedback and demonstrates efforts to improve own performance· ____ Provides feedback to appropriate colleagues and leaders to promote quality improvement
Student Comments:
Role 4 (R4): Member of Healthcare Team. Domain 6 (R4-D6): Inter-professional PartnershipsCompetencies: Teamwork, Collaboration, and CommunicationNP: Interprofessional Collaboration in Practice
· ____ Monitors and reports changes promptly and with accuracy· ____ Evaluates immediate and/or necessary interventions· ____ Collaborates and/or consults with members of the healthcare team regarding variations in health outcomes· ____ Assists other team members with care or tasks as consistent with own education and capabilities· ____ Uses therapeutic communication with clients and staff· ____ Recognizes communication barriers; alert to nonverbal cues
Student Comments:
Domain 7 (R4-D7): Systems-Based PracticeCompetencies: Diversity, equity, and inclusion in healthcare and advocate for the Profession and Patient Care. NP: Health Systems
· ____ Informs patients regarding their plans of care· ____ Encourages patient participation in decision-making to ensure consistency and accuracy in their care· ____ Assesses the adequacy of the resources and support systems available for patient care· ____ Provides holistic, patient-centered safe nursing care in a compassionate, caring, nonjudgmental, culturally appropriate, non-discriminatory manner· ____ Demonstrates concern for client’s safety, welfare, and dignity· ____ Identifies cultural and spiritual differences that impact care and communication· ____ Shows respect for the inherent dignity of every human being regardless of age, gender, religion, socioeconomic class, sexual orientation and ethnicity. · ____ Demonstrates sensitivity and concern for others; recognizes cultural issues and interact with clients in culturally sensitive ways.· ____ Makes decisions so problems are solved in precise and equitable ways by incorporating cultural preferences, health beliefs, behaviors, and practices into the management of care
Student Comments:
Domain 8 (R4-D8): Information and Healthcare TechnologyCompetencies: Informatics. NP: Technology and Information Literacy Competencies
· ____ Uses technology for assessment, provision of care and evaluation of care and client’s responses to care· ____ Skillfully uses equipment according to its function and ensures competency with new equipment, technology and electronic data access· ____ Updates electronic health record in timely manner with accurate data· ____ Adheres to information management policies
Student Comments:
Average score and Grade Conversion per chart

NURS 5323 Module 9

Overview

Readings: Leifer & Fleck: Chapter 8

PowerPoint

Attached Files:

o Leifer – Chapter 8 Book Powerpoint (59.07 KB)

Texas Health Steps Modules Week 9

Due Saturday 23:59

Go to https://www.txhealthsteps.com/courses
Complete the required modules:

ADHD: Screening, Diagnosis and Management
Autism Spectrum Disorder: Screening, Diagnosis and Management
Childhood Anxiety Disorder
Identifying and Treating Children with Asthma

Submit a PDF copy of the CE certificate/proof of completion.

NURS 5323 Module 10

Readings: Leifer & Fleck: Chapter 8

PowerPoint

Attached Files:

o Leifer – Chapter 8 Book Powerpoint (59.07 KB)

Texas Health Steps Modules Week 10

Due Saturday 23:59

Go to https://www.txhealthsteps.com/courses
Complete the required modules:

Hearing and Vision Screening
Diabetes Screening, Diagnosis and Management
Exercise-Induced Dyspnea

Submit a PDF copy of the CE certificate/proof of completion.

Well-Visit Case Write-Up #1

Attached Files:

o 2021EMCoding (222.35 KB)

o MSN Well-Visit Case Write Up Assignment Instructions & Rubric_HCU_08.01.23.docx (94.957 KB)

o Growth and Development Template_HCU_08.01.23.docx (62.688 KB)

Please use attached instructions to complete the assignment. Due Saturday 23:59

FNP students: If Well-Visit Case Write-Up #1 is completed on a pediatric patient, then you will have to select an adult patient for Well-Visit Case Write-Up #2. If Well-Visit Case Write-Up #1 was completed on an adult patient, then you will have to select a pediatric patient for Well-Visit Case Write-Up #2.

PNP-PC students: Pay attention to the developmental stage of the patient selected for Well-Visit Case Write-Up #1. You must select a patient of a different developmental stage for Well-Visit Case Write-Up #2.

School of Nursing and Allied Health – MSN Well-Visit Case Write Up Assignment

The purpose of the Well Visit Case Write- Up Assignment is for your instructor to “see” what you are doing in clinical and “see” how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.

Make sure to start “fresh.” Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.

Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, just put a note at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.

If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write an Addendum at the end of the write-up to let your instructor know that you are aware and what you would have done.

You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum.

You are learning to practice evidence-based practice. Support items in your assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your write-up is using a research article. Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)

Note that you CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups

All case write ups are to be submitted to the appropriate assignment category by the due date. Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requested and approved before the due date.

When submitting case write up in Blackboard, the assignment will submit to a plagiarism detection software. Plagiarism detection software is used by HCU to identify plagiarized assignments. We are aware of the difference between high “copy matches” due to copied things such as titles/headings and significant matches that were inappropriately copied from another paper. Unfortunately, we have seen some of the latter and it is generally not difficult to tell the difference between the two since we can immediately see every word of the other papers. If a paper has significant or complete sections of copied material, a grade of zero will be assigned to the paper.

Well-visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam (may not always include head to toe, but could be the only preventive care most women receive), well-child exam, or new or established patients with complex or chronic diseases or comorbidities. This write up should be 5-8 pages (excluding title page, APA reference list, and templates)

This assignment is designed to promote the development of the following: AACN Essentials (2022): Domains 1, 2, 4, 6, and 9 and NONPF NP Core and Population-Focused Competencies (2012;2017): Scientific Foundational, Practice Inquiry, Technology and Information Literacy, and Independent Practice.

Case Write-up Outline

Following the format of: https://meded.ucsd.edu/clinicalmed/write.htm.

Subjective:

CC: This should be in quotes: “I am here for an annual physical.”

HPI: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases.

Past Medical History: Past or present illness. Be careful with “blindly” copying history from a prior clinical note.

Past Hospitalizations: Past hospitalizations with reason for admit, duration of stay, and rough dates

Past Surgical History: Past surgeries and rough dates when possible.

Medications: List name, dose, frequency and indication (why are they taking it?) Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether you’ve put all important information in your patient history. If a patient is taking Metformin and there’s no related information on the history and/or diagnoses list, something is missing.

Allergies: Medications, Food allergies when applicable. Specify what type of reaction next to the allergy if known by the person you are collecting history from (E.g., Penicillin-rash)

Social History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunization is important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, don’t just say UTD. For pediatrics: list dates for all immunizations

Other pediatric considerations: list who all lives in home with patient, how many siblings with ages next to them, type of home, any pets inside/outside home & what type of pet, any smoking in home, any guns in home; if young child are they in daycare or if babysitter or family member or parent stay home with child, are they in school & what grade and what type of grades does the child make, list any extracurricular activities, any problems with school or teacher, any recent social or home changes. If they are pre-teen and older- add alcohol use, smoking, sexual history, work history, etc.

Family History: It is generally appropriate to go back at least two generations. State family member (mom/dad/maternal grandparents/paternal grandparents/siblings/etc.), their age & if they’re alive, write unknown if history not known, write any conditions or illnesses next to each person, if they are deceased write deceased and any illnesses/conditions for them also.

Obstetrical History: When appropriate, document number of pregnancies and other relevant information.

Birth History – applicable for pediatric write ups especially for young pediatric patients

Review of Symptoms (ROS): Should be extensive and include every system. Always address growth and development in pediatric patients. Nutrition should be addressed, especially in pediatric patients. In childbearing women (any teen or female who have reached menarche), make sure to document date of last menstrual period (LMP) and methods of contraceptive use on every visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation/hysterectomy).

Every visit – If you order such a medication without documenting the above information, we have to assume that the patient could be pregnant (as would any lawyer in a lawsuit). For a young teen you can put “not sexually active” (but make sure you have asked). This is sometimes tricky with teens being seen for general health problems but so very important. If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone. Data should be systemically presented.

Objective

Vital signs (BMI should be included on every visit)

Physical examination: This is head to toe detailed and thoroughly describe findings within ALL systems. Do not put within normal limits (WNL). Make sure to describe all findings. Findings should be displayed in a systematic fashion.

Laboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but results were not available.

TIP:

Make sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, Social/family history, and Review of system (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and/or diagnostic test results.

Note that statement such as “Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.” should be in the subjective section (ROS) of your note, and not in PE section. Do not write “Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature” under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.

Assessment

For a well-visit case write up, you should document at least three ICD code diagnoses.

Please remember support your indicated diagnosis with evidence-based reference, provide citation and supportive information.

You will create a Growth and Development template. You should use resources from the course, previous courses, and current evidence-based sources to complete your template. Cite appropriately. The Growth and Development template can be located in Appendix A. It should be attached to the end of the write-up

Template will require APA-formatted in-text citations. Sources should be listed in the reference list.

Plan

Include medications ordered, labs tests, teaching, referrals, and when the patient needs to follow-up. Explain rationale for all orders: laboratory test, imaging, medications. All write-up plans should include documentation of patient education, especially if medication is prescribed and anticipatory guidance. Health maintenance such as screening for breast or colon cancer, should be addressed. Please be sure this information is organized under each diagnosis; keeping it organized helps the write up flow well to where the reader is able to get a clear picture of everything you did during the patient encounter.

Coding Resource:

All write ups should include the billing codes. We do not expect you to memorize these codes. You can get them from the billing form that the physician or NPs uses in the office. You can put the billing codes at the end of the write-up. You should include both the E&M code (level of service) and the ICD-10 diagnosis codes. Your E&M code should be consistent with your patient visit.

Addendum

***Remember to add an additional note at the end of the write up if you realized anything was missing from the encounter that should have been done or ordered. Put it at the end of your write up and label it: Addendum ***

MSN Well-Visit Case Write-Up Rubric

Criteria	Exceeds Expectations	Meets Expectations	Below Expectations	No Effort
Chief Complaint(CC)	3 Points Includes CC includes the reason for visit, is appropriate for the type of write-up AND is in the patient/family’s own words.	2 Points Includes CC that includes the reason for visit, is appropriate for the type of write-up but is not in the patient/family’s own words	1 Point CC is not appropriate for the type of write-up AND is not in the patient/family’s own words	0 Points Not included
History of Present Illness(HPI)	10 pointsProvides a comprehensive HPI that includes all the pertinent information and excludes irrelevant information.HPI is focused and detailed.Does not include any objective data	7 pointsProvides a HPI that includes pertinent information but misses 1 -2 key components and/or includes information that is irrelevant to the patient visit.HPI is somewhat focused.	4 pointsProvides a superficial HPI that misses 3 or more key components or does not include all pertinent informationHPI includes irrelevant information ORIncludes objective data	0 PointsNot included
Medications	3 PointsDocuments a comprehensive medication list that includes drug name (brand and generic), dosage, route, frequency and indication.Allergies are documented and includes reaction.Includes NDKA, if applicable.	2 PointsDocumentation includes medication list but omits 1-2 details.Fails to include PRN medicationsAllergies are documented but does not include reaction.	1 PointDocumentation includes medications but omits 3 or more details.Allergies are not addressed	0 PointsNot included
Pertinent History	10 PointsProvides comprehensive past medical history, surgical, family, social, obstetrical history, and birth history (when applicable).History is consistent with other documentation.Includes immunization information	7 PointsProvides a history but history is superficial OROmits 1 -2 necessary details	4 PointsProvides a history but history of superficialOmits 3 or more details	0 PointsNot included
Review of Systems	10 PointsComplete ROS that addresses each physical systemROS is completed with a clear narrative in systematic fashion.Does not include any objective dataDo not write within normal limit or other variations. If documented abnormalities, states what is considered ‘normal’	7 Points Incomplete ROS that misses 1-2 components	4 PointsIncomplete ROS that misses 3 or more componentsORIncludes objective data	0 Points No ROS attempted
Objective Data	16 PointsDocuments vital signs with documented BMI (when appropriate)Documents physical examination:Each system addressed completely and presented in systematic fashionInclude pertinent positive and pertinent negative findings.Documents labs, diagnostic tests that are available for that visit.Does not include any subjective data	10 PointsDocuments vital signs but is missing BMIDocuments an incomplete physical examination:missing 1-2 components and/or missing up to 2 pertinent positives/negatives Documents labs, diagnostic tests that should be a part of the planIncludes subjective data	6 PointsDoes not document vital signsDocuments an incomplete physical examination:missing 3 or more of the components and/ or missing 3 or more pertinent positives/negatives Fails to document labs, diagnostic tests	0 PointsNot included
Assessment	20 PointsProvides at least 3 diagnoses that are relevant to the patientICD-10 codes included with each diagnosisGrowth and Development template is relevant to the patient.Template is fully completed and contains accurate and current informationTemplate is supported by evidence-based sources	14 PointsProvides only 2 diagnosesDoes not include ICD-10 codesGrowth and development template completed and relevant to the patient but missing 2-3 componentsTemplate is not supported by evidence-based sources	7 PointsProvides only 1 diagnosisDiagnoses not relevant to the patientGrowth and Development template completed but not relevant to the patientTemplate missing 4 or more components	0 Points No effort
Plan	18 PointsProvides a plan that includes appropriate labs/tests ordered that are pendingProvides rationale including labs, imaging, and other testing using evidence-based sourcesIncludes medications ordered and/or refilled and details about dosing and instructions, and patient teaching are included.Plan includes both pharmacological and non-pharmacological interventionPlan includes referrals and follow up detailsOrders are appropriate for patient visit and consistent with best practicesCitations for sources of interventionCoding and Billing included	12 PointsMissing 2-3 componentsDoes not include dosing and instructions for medicationsDoes not provide rationale for orders using evidence-based sourcesDoes not include Coding and Billing	6 PointsMissing 4 or more of the required components Plan is not supported by evidence and citations for sources of intervention are missingDoes not include Coding and Billing	0 PointsNot included or inappropriate to patient visit
Formatting/APA	10 PointsNo errors in grammar and spellingNo errors in APA formatWrite-up is in proper format and adheres to the appropriate page limits.	7 PointsUp to 2 spelling or grammar errorsUp to 2 APA errors	4 Points3-4 errors in spelling or grammar3-4 APA errorsWrite-up is not in proper format OR does not adhere to the appropriate page limits	0 Points5 or more errors in spelling or grammarOR 5 or more APA errors

Appendix A

Growth and Development Template

Developmental Stage: ________________________________________________________________

Growth and Development Template

Developmental Stage: ______________________________________________________________

NURS 5323 Module 11

Readings: Leifer & Fleck: Chapters 9

PowerPoint

Attached Files:

o Leifer – Chapter 9 Book Powerpoint (82.639 KB)

Texas Health Steps Modules Week 11

Due Saturday 23:59

Go to https://www.txhealthsteps.com/courses
Complete the required modules:

Tuberculosis Screening, Testing and Treatment: A Guide for Texas Health Steps Providers
Behavioral Health: Screening and Intervention
Sports-Related Concussion: Diagnosis, Treatment and Prevention
High-Risk Behaviors in Young People: Screening and Intervention
Submit a PDF copy of the CE certificate/ proof of completion.

NURS 5323 Module 12

Readings: Leifer & Fleck: Chapters 10

PowerPoint

Attached Files:

o Leifer – Chapter 10 Book Powerpoint (74.193 KB)

Texas Health Steps Modules Week 12

Due Saturday 23:59

Go to https://www.txhealthsteps.com/courses
Complete the required modules:

Adolescent Substance Use
Childhood and Adolescent Depression
Promoting Adolescent Health
Teen Consent and Confidentiality

Submit a PDF copy of the CE certificate/ proof of completion.

Adolescence Discussion Board Case Study

A 16-year-old adolescent girl presents for a routine wellness examination. She is a junior in high school and has no significant medical history. She plays on the school softball team and has a preparticipation clearance form for you to complete. She is accompanied by her mother who wants to know if her daughter should start having routine gynecologic examinations as part of her routine check-up.

She states that the patient’s last tetanus shot was at the age of 5. She received all of the routine childhood immunizations, including a complete hepatitis B series, and had chickenpox when she was 6 years old despite being vaccinated for varicella. The mother reports that there are no medical problems in the immediate family, but that one of the patient’s cousins died at the age of 21 of sudden cardiac death.

When interviewed without the mother in the room, the patient reports to you that she is generally happy, she gets As and Bs in school and has an active social life. She denies ever being involved in sexual activity, or tobacco or drug use. She says that she will have a “drink or two” at a party with her friends. On examination, her vital signs are normal.

Examination of her head and neck, lungs, abdomen, skin, and musculoskeletal and nervous systems are normal. On cardiac auscultation, you hear a 2/6 systolic murmur that gets louder when you have her Valsalva. Peripheral pulses are strong and symmetric; there is good capillary refill and no sign of cyanosis.

Answer questions 1- 5 using course resources and at least one additional scholarly resource found outside the course resources.

What immunizations should be recommended at this visit?
At what age is it recommended to start routine Pap smear screening?
Would you sign or not sign the pre-participation form? Why or why not?
What is the most common cause of sudden cardiac death in young athletes?
What anticipatory guidance would you provide?

Deliverable Instructions:

You will not be able to see posts until you post yours.
Initial post by Wednesday 23:59.
Replies to peers by Friday 23:59.
Additional replies as appropriate by Saturday 23:59 (closing the loop).
Initial discussion post word count should be no more than 500 words.
Reply posts should be no more than 350 words.
Late posts will incur a 10% penalty per day.
For grading criteria, see Discussion Board Participation Rubric.

NURS 5323 Module 13

Review as Needed

Exam 2 will open on Wednesday at 0000 and close on Saturday at 2359. The exam will not be visible in this Module or your Blackboard calendar until the exam opens.

Clinical Update #2

Attached Files:

TyphonUpdateExample_HCU_08.01.23.docx (281.233 KB)
Clinical Hour Log_HCU_08.01.23.docx (52.641 KB)
MSN Personal Clinical Objectives Update Template_HCU_08.01.23.docx (56.607 KB)
MSN Nurse Practitioner Clinical Update Assignment Instructions and Rubric_12.2023.docx (61.745 KB)
MSN Clinical Update Form_HCU_08.02.23.docx (48.557 KB)
NONPFCoreCompetencies2022.pdf (175.008 KB)

Due Saturday 23:59
Please read the instructions in the attached document to work on this assignment.

School of Nursing and Allied Health – MSN Clinical Update Assignment Instructions and Rubric

Instructions: The assignment has four components:

5. Grad CPAT Student Reflection Form (Clinical Update #1)

Clinical Update Form (Clinical Update #2)

Students will type answers to prompts directly on the form. Answers should be thorough and show deep reflection of the student’s clinical experience. Each prompt must be addressed.

6. MSN Personal Clinical Objectives Update

7. Typhon Update

8. Clinical Hours Log

MSN Clinical Update Assignment Rubric

Criteria	Meets Expectations	Needs Improvement	Does not meet Expectations
Graduate CPAT Self-Reflection Form / Clinical Update Form	40 points · Graduate CPAT Self Reflection Form / Clinical update form submitted on appropriate template· Student answers show thorough reflection and insight into clinical experience/progress· Each prompt is addressed· 0-2 grammatical or spelling errors	20 points · Superficial responses to question prompts· Missing one or more components· More than 3 grammatical or spelling errors	0 Points · Not submitted
Personal Clinical Objectives Update	15 Points · Personal objective update submitted on appropriate template and in appropriate format· Reflections show thorough insight into progress with 1-2 cases as examples for met objectives· 0-2 grammatical or spelling errors	7.5 points · Superficial responses to question prompts· Missing one or more components· More than 3 grammatical or spelling errors	0 Points · Not submitted
Typhon Update	30 points · Typhon log pdf submitted to Blackboard· Case logs are up-to-date· Case logs are in proper format	15 points · Missing one or more components	0 Points · Not submitted
Clinical Hours Log	15 Points · Clinical log accurate with preceptor’s signature· Clinical hours log match the latest submitted clinical schedule and Typhon history	7.5 Points · Clinical log missing dates and/or not signed by preceptor· Clinical hours log does not match submitted clinical schedule and Typhon history	0 Points · No submitted

NURS 5323 Module 14

Readings: Leifer & Fleck: Chapters 11–13

PowerPoints

Attached Files:

Leifer – Chapter 11 Book Powerpoint (76.437 KB)
Leifer – Chapter 12 Book Powerpoint (68.998 KB)
Leifer – Chapter 13 Book Powerpoint (79.977 KB)

Texas Health Steps Modules Week 14

Due Saturday 23:59

Go to https://www.txhealthsteps.com/courses
Complete the required modules:

Preventing Unintentional Injury
Transition to Adult Care: Services for Children and Youth with Special Health-Care Needs
Interpersonal Youth Violence

Submit a PDF copy of the CE certificate/ proof of completion.

NURS 5323 Module 15

Readings: Leifer & Fleck: Chapters 14–16

PowerPoints

Attached Files:

Leifer – Chapter 14 Book Powerpoint (79.964 KB)
Leifer – Chapter 15 Book Powerpoint (76.771 KB)
Leifer – Chapter 16 Book Powerpoint (66.206 KB)

Well-Visit Case Write-Up #2

Attached Files:

2021EMCoding (222.35 KB)
MSN Well-Visit Case Write Up Assignment Instructions & Rubric_HCU_08.01.23.docx (94.957 KB)
Growth and Development Template_HCU_08.01.23.docx (62.688 KB)

Please use the attached instructions to complete the assigment due Saturday 23:59.

FNP students: If Well-Visit Case Write-Up #1 was completed on a pediatric patient, then select an adult patient for Well-Visit Case Write-Up #2. If Well-Visit Case Write-Up #1 was completed on an adult patient, then select a pediatric patient for Well-Visit Case Write-Up #2.

PNP-PC students: Select a patient of a different developmental stage that the patient selected for Well-Visit Case Write-Up #1

Typhon Complete

Due Saturday 23:59

Submit the following when you are ready for the instructor to verify you have completed the required hours:

Screenshot of your Typhon hours in pdf format
Complete Clinical Hours Log signed by preceptor

Preceptor Evaluation of Student

Attached Files:

Due Saturday 23:59

Submit completed form (Page 1) with the preceptor and student signatures. The preceptor should use Pages 2-6 for grading guidance. If the preceptor prefers to complete it electronically, please download and send the fillable PDF file.

Clinical Faculty Evaluation of Student

Attached Files:

GCPAT Clinical Faculty Grading Form and Instructions_Fillable_HCU_08.02.23.pdf (134.677 KB)
Grad CPAT Nurse Practitioner Student Reflection Form_HCU_08.02.23.docx (61.756 KB)

Due Saturday 23:59

Please complete the GRADUATE CLINICAL PERFORMANCE ASSESSMENT TOOL (GCPAT)— Student Self-Reflection Worksheet end of the semester review and submit. Do not forget to self-score yourself in each Domain. Clinical faculty will complete the GCPAT Grading form.

School of Nursing and Allied Health – MSN Well-Visit Case Write Up Assignment

Note that you CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups

Case Write-up Outline

Following the format of: https://meded.ucsd.edu/clinicalmed/write.htm.

Subjective:

CC: This should be in quotes: “I am here for an annual physical.”

Past Medical History: Past or present illness. Be careful with “blindly” copying history from a prior clinical note.

Past Hospitalizations: Past hospitalizations with reason for admit, duration of stay, and rough dates

Past Surgical History: Past surgeries and rough dates when possible.

Allergies: Medications, Food allergies when applicable. Specify what type of reaction next to the allergy if known by the person you are collecting history from (E.g., Penicillin-rash)

Obstetrical History: When appropriate, document number of pregnancies and other relevant information.

Birth History – applicable for pediatric write ups especially for young pediatric patients

Objective

Vital signs (BMI should be included on every visit)

Laboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but results were not available.

TIP:

Assessment

For a well-visit case write up, you should document at least three ICD code diagnoses.

Please remember support your indicated diagnosis with evidence-based reference, provide citation and supportive information.

Template will require APA-formatted in-text citations. Sources should be listed in the reference list.

Plan

Coding Resource:

Addendum

MSN Well-Visit Case Write-Up Rubric

Criteria	Exceeds Expectations	Meets Expectations	Below Expectations	No Effort
Chief Complaint(CC)	3 Points Includes CC includes the reason for visit, is appropriate for the type of write-up AND is in the patient/family’s own words.	2 Points Includes CC that includes the reason for visit, is appropriate for the type of write-up but is not in the patient/family’s own words	1 Point CC is not appropriate for the type of write-up AND is not in the patient/family’s own words	0 Points Not included
History of Present Illness(HPI)	10 pointsProvides a comprehensive HPI that includes all the pertinent information and excludes irrelevant information.HPI is focused and detailed.Does not include any objective data	7 pointsProvides a HPI that includes pertinent information but misses 1 -2 key components and/or includes information that is irrelevant to the patient visit.HPI is somewhat focused.	4 pointsProvides a superficial HPI that misses 3 or more key components or does not include all pertinent informationHPI includes irrelevant information ORIncludes objective data	0 PointsNot included
Medications	3 PointsDocuments a comprehensive medication list that includes drug name (brand and generic), dosage, route, frequency and indication.Allergies are documented and includes reaction.Includes NDKA, if applicable.	2 PointsDocumentation includes medication list but omits 1-2 details.Fails to include PRN medicationsAllergies are documented but does not include reaction.	1 PointDocumentation includes medications but omits 3 or more details.Allergies are not addressed	0 PointsNot included
Pertinent History	10 PointsProvides comprehensive past medical history, surgical, family, social, obstetrical history, and birth history (when applicable).History is consistent with other documentation.Includes immunization information	7 PointsProvides a history but history is superficial OROmits 1 -2 necessary details	4 PointsProvides a history but history of superficialOmits 3 or more details	0 PointsNot included
Review of Systems	10 PointsComplete ROS that addresses each physical systemROS is completed with a clear narrative in systematic fashion.Does not include any objective dataDo not write within normal limit or other variations. If documented abnormalities, states what is considered ‘normal’	7 Points Incomplete ROS that misses 1-2 components	4 PointsIncomplete ROS that misses 3 or more componentsORIncludes objective data	0 Points No ROS attempted
Objective Data	16 PointsDocuments vital signs with documented BMI (when appropriate)Documents physical examination:Each system addressed completely and presented in systematic fashionInclude pertinent positive and pertinent negative findings.Documents labs, diagnostic tests that are available for that visit.Does not include any subjective data	10 PointsDocuments vital signs but is missing BMIDocuments an incomplete physical examination:missing 1-2 components and/or missing up to 2 pertinent positives/negatives Documents labs, diagnostic tests that should be a part of the planIncludes subjective data	6 PointsDoes not document vital signsDocuments an incomplete physical examination:missing 3 or more of the components and/ or missing 3 or more pertinent positives/negatives Fails to document labs, diagnostic tests	0 PointsNot included
Assessment	20 PointsProvides at least 3 diagnoses that are relevant to the patientICD-10 codes included with each diagnosisGrowth and Development template is relevant to the patient.Template is fully completed and contains accurate and current informationTemplate is supported by evidence-based sources	14 PointsProvides only 2 diagnosesDoes not include ICD-10 codesGrowth and development template completed and relevant to the patient but missing 2-3 componentsTemplate is not supported by evidence-based sources	7 PointsProvides only 1 diagnosisDiagnoses not relevant to the patientGrowth and Development template completed but not relevant to the patientTemplate missing 4 or more components	0 Points No effort
Plan	18 PointsProvides a plan that includes appropriate labs/tests ordered that are pendingProvides rationale including labs, imaging, and other testing using evidence-based sourcesIncludes medications ordered and/or refilled and details about dosing and instructions, and patient teaching are included.Plan includes both pharmacological and non-pharmacological interventionPlan includes referrals and follow up detailsOrders are appropriate for patient visit and consistent with best practicesCitations for sources of interventionCoding and Billing included	12 PointsMissing 2-3 componentsDoes not include dosing and instructions for medicationsDoes not provide rationale for orders using evidence-based sourcesDoes not include Coding and Billing	6 PointsMissing 4 or more of the required components Plan is not supported by evidence and citations for sources of intervention are missingDoes not include Coding and Billing	0 PointsNot included or inappropriate to patient visit
Formatting/APA	10 PointsNo errors in grammar and spellingNo errors in APA formatWrite-up is in proper format and adheres to the appropriate page limits.	7 PointsUp to 2 spelling or grammar errorsUp to 2 APA errors	4 Points3-4 errors in spelling or grammar3-4 APA errorsWrite-up is not in proper format OR does not adhere to the appropriate page limits	0 Points5 or more errors in spelling or grammarOR 5 or more APA errors