cc/HPI- 29 YO F presents to the office for f/u appt s/p sleep study test.During initial appointment , pt presented w c/o increased lethargy. Sleep study was conducted which revealed Pt has mild sleep apnea. 55 apnic ep. 5 w desaturation. According to Respiratory therapist, pt is in need of positive air pressure machine; settings 4cm h20.
PE- pt displays no evidence of discomfort. lungs sounds are clear with no adventitious sounds. CV assessment WNL. No cyanosis present. capillary refill less than 3secs.
Impression/plan – sleep apnea. PAP machine settings 4cm h20. education on pap machine and risks of noncompliance
cpt- 99214
CASE STUDY and EVIDENCE BASED GUIDELINE PRESENTATIONS
With approval from the faculty, the student will select a patient to present in class (see above for patient info). The student will create a recorded PowerPoint presentation and post the presentation in he discussion board. Presentations should be about 15 – 20 minutes long. The student will include discussion question/s for the class to respond to.
Students should present a case study in a SOAP format (see guide). Topics for presentation should include:
- Annual visit – Health promotion and screening
- Patients with low severity problem; with no comorbidities or uncomplicated comorbidities. Examples of disease conditions:
- Dermatology disorders
- ENT disorders
- Lung disorders: acute bronchitis
- CV Disorders: HTN, hyperlipidemia
- Endocrine: Thyroid disorders
- Neuro: headaches, migraine
- MS: back pain, OA
- GU: UTI, STD
Subjective
Chief Complaint (CC). The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint. If the patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it.
History of Present Illness (HPI). Present the most important problem first. If there is more than one problem, treat each separately. Present the information chronologically. Cover one system before going onto the next. Characterize the chief complaint – quality, severity, location, duration, progression, and include pertinent negatives.
Review of Systems (ROS). Include only the pertinent systems. Most of the ROS is incorporated in the HPI.
Past Medical and Surgical History (PM/SH). Discuss other past medical history that bears directly on the current medical problem.
Allergies/Medications. Present all current medications along with dosage, route and frequency.
Social/Work History. Smoking, alcohol and recreational drug use. Home, environment, work status and sexual history (if pertinent).
Family History. Note particular family history of genetically based diseases.
Objective
Physical Exam. Include a focused assessment. Include all significant abnormal findings and any normal findings that contribute to the diagnosis.
Labs/Other Tests. Review laboratory or diagnostic tests done with results.
Assessment
Working Diagnosis/Differential Diagnoses. Provide a summary of the important aspects of the history, physical exam, lab/diagnostic tests and formulate the differential diagnoses and working diagnosis. Provide at least one working diagnosis and three differential diagnoses.
Plan Discuss the actual management of the patient including pharmacologic and non- pharmacologic management. Discuss the follow up plan for the patient, if necessary.
| Case Presentation with relevant patient information – not more than 3-5 slides | 20% |
| Guideline presentation – based on peer reviewed data (5-8 slides) | 25% |
| Recommendations/interventions are formulated that may be applied to the situation based on advanced nursing practice competencies. | 25% |
| Certification questions – Provide 5 certification questions on the topic presented. (Do NOT include answers) | 5% |
| Power point presentation is organized in a clear, concise manner, thoughtful. References. | 10% |
| Summary of seminar discussion is provided. Knowledge and skill in leading the discussion are demonstrated and interactions with peers are based on adult learning principles. | 15% |
| Total | 100% |
| SOAP NOTE RUBRIC | Not Acceptable | Needs Improvement | Proficient | Excellent |
| Subjective (25 points) | Subjective assessment is missing several critical elements needed to adequately evaluate the client problem. Irrelevant information predominates subjective assessment. 0 points | Subjective assessment is missing 3-4 key elements needed to adequately evaluate the client’s problem. Includes irrelevant information. 10 points | Subjective assessment is missing 1-2 key elements needed to adequately evaluate the client’s problem. 20 points | Subjective assessment of health status is focused and fully explicated. CC is succinct. HPI information is fully developed and included. Elements of the PMH, FH, and ROS that expand on the CC and HP information are included and organized appropriately. 25 points |
| Objective (25 points) | Objective assessment is not well developed, missing several elements and/or the assessment is inappropriate. 0 points | Objective assessment is missing 3-4 key elements to adequately evaluate the client’s problem. 10 points | Objective assessment is missing 1-2 key elements to adequately evaluate the client’s problem. 20 points | Objective assessment of health status is fully explicated. Includes appropriate and relevant data. 25 points |
| Assessment with ICD-10 codes (15 points) | Inappropriate final diagnosis. 0 points | Final diagnoses considered is incomplete or only minimally applicable for assessments. Missing ICD-10 codes or other problems not identified. 5 points | Appropriate final diagnosis selected, limited problem list identified, may be missing ICD 10 or limited subjective and objective data to support diagnosi/es. Incomplete problem list. 10 points | Complete problem list identified (when applicable) with an optimal assessment for each problem. ICD-10 codes are included and accurate. Accurate problem identification and prioritization supported logically by the subjective and objective data. Exhibits clear understanding of the patient’s current condition(s). 15 points |
| Plan (25 points) | Plan is inappropriate, lacking essential components related to final diagnoses. 0 points | Plan is inadequate to fully address the identified problem. Needs to consider alternatives for optimal outcomes or lacking use of clinical guidelines. 10 points | Plan is appropriate and meets criteria but is not individualized for the client. 20 points | Plan is appropriate and comprehensive for diagnosis and adequately addresses the problem identified. Plan is economically sound and utilizes the current clinical guidelines. Plan should include appropriate health promotion an dhealth screening interventions. 25 points |
| Differential Diagnoses Evidence-Based Rationale (10 points) | Missing differential diagnoses and evidence-based rationale. 0 points | Limited differential diagnoses considered and/or final diagnoses, missing evidence based rationale to support diagnoses on 2 or more diagnoses. Evidence-based rationale is incomplete. 5 points | Limited differential diagnoses or limited evidenced based rationale to support diagnoses on 2 diagnosis provided. Evidence-based rationale is provided but not fully explicated. 7 points | Identifies 3 appropriate differential diagnoses with a brief rationale to support the consideration of these diagnosis Provides a rationale of the plan (above). Plan is supported by the latest clinical guidelines. Appropriate citation and evidence-based references provided. 10 points |