Include information in regards to the pathophysiology related to the main diagnosis or illness process. This will help to understand how the S and O supported this diagnosis.
Diagnostic Tests: This area is for tests for Atrial Fibrillation (e.g. EKG, troponin, CXR, etc)
Assessment (number each diagnosis):
• Medical Diagnosis: Start with the presenting complaint diagnosis first. Number each diagnosis. A statement of the current condition of all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the S and O must support this diagnosis. Pertinent positives and negatives must be found in the write-up.
Plan (number each plan specific to each diagnosis):
These are the interventions that relate to the above diagnosis and address the following aspects (they may be included in one paragraph or separated out as listed
Diagnostic: labs, diagnostics
Therapeutic: changes in meds, skin care, counseling
Educational information clients need to address their health problems. Include
follow-up care. Anticipatory guidance and counseling
Consultation/Collaboration referrals, or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care
Clinical Decision Making
The final section summarizes your critical thinking, decision-making and diagnostic
reasoning skills and is a mandatory additional requirement of this assignment.
It is a reflection of the thought process you used in caring for the patient.
Follow the directions under each section and label each area as appropriate.
ALL information should be in your own words.
Leadership / Professional Role:
Identify the specific person that drove this plan of care and developed the management,
while including detail in how you advocated for the patient. Also include how
you identified your advocacy for the role of the Nurse Practitioner. Include
how an individualized approach was applied to this patients care.
Pharmacology information (1 paragraph): CARDIZEM
Please include the name of the drug (generic and brand),
class, action, excretion, side effects and interactions, why this particular
drug is being prescribed for this particular patient, what is this drug
intended to treat, (specifically antibiotics, what organisms are we treating?).
What other drug could be chosen instead that would work? Keep in mind the cost
and convenience for the patient. This should be about a paragraph in length
stated in the way that you would use to educate your patient regarding the
medication. It is not acceptable to copy and paste from your pharmacology
resource or text. Please cite resources used.
Critical Thinking / Clinical Decision
Making: (1 paragraph)
In this section, include the top 2-3 differential diagnosis. This is an area that you would want to discuss what led to the diagnosis and how you ruled out certain other differential diagnosis. You may want to include why a particular treatment was chosen, perhaps despite what the books and references say. You need to provide evidence that you are referring to your available resources and not just deferring to your preceptor. Address any personal biases related to aging, development, and independence that might interfere with delivering quality of care.
Evidence based practice (1-2 paragraphs)
Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings. The practice of Evidence-Based Practice includes five fundamental steps;
•Formulating a well-built question
•Identifying articles and other evidence-based resources that answer the
•Critically appraising the evidence to assess its validity
•Applying the evidence
•Re-evaluating the application of evidence and areas for improvement
In this section please include APA citation for all resources utilized that informed your decision making with this particular patient case. In addition, describe what clinical questions and terms used to direct your search and address how valuable the evidence you found was in understanding, and directing the care.
Critique (1 paragraph)
This is an area where you look over the data gathered and after a careful review of the available resources (i.e. text books, reference readings) will provide a reflection of what might have been added or deleted that would have made this note more conclusive or complete. This is not an area to critique the preceptor. What areas could you have changed? What areas might you have added, perhaps additional questions you should have asked in the ROS, or additional areas you may have assessed for in the PE?