NURS 601B APRN Bridge course Week 7 Assignment Comprehensive H&P Case Study

NURS 601B APRN Bridge course

Week 7 Assignment

Comprehensive H&P Case Study

The purpose of this paper is to understand the importance of accurate medical record documentation to record pertinent facts, findings, and observations about a patient’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.

Directions:

Step 1:

Review and critique the comprehensive H&P and thoroughly answer the questions that follow in complete sentences and paragraphs using question and answer APA format.

Step 2:

Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.

Step 3:

Keep in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by CMS. Visit CMS.gov, and then search “1997 Guidelines of Documentation for Evaluation and Management” for information that should be included in a medical record.

Answer the following questions:

1. Does this document meet the CMS guidelines for documentation of a comprehensive history and physical? Why or why not? Be specific.

2. Critically analyze the H&P and list any errors. Identify the strengths of the H&P.

3. Did any questions come to mind that you are unable to answer after reading the H&P?

4. Are the conditions listed in the assessment section reasonably supported by the history? Why or why not? Explain your rationale.

5. Did you identify other differential diagnoses or conditions that should be included in the assessment? If so, list them.

6. List the ICD-10 code for each of the following (go to CMS.gov and search for the ICD-10 Codes):

Moderate persistent asthma with (acute) exacerbation: ______________

Pneumonia, unspecified organism: ______________

Essential (primary) hypertension: ______________

Hyperlipidemia, unspecified ______________

Obesity: ______________

7. Is it appropriate to include the ICD-10 code for pneumonia when billing for this visit? Why or why not?

8. Is the plan reasonable based on the assessments listed? Why or why not?

9. List 3 patient education strategies relevant to the case study including specific medication teaching. Include references.

10. List health promotion recommendations from AHRQ according to age/gender/conditions. Cite your references.

Your paper should be 2-3 pages not including the title and reference pages. A minimum of 2 sources, not including your texts, must be incorporated into your paper.

601B Comprehensive H&P guidelines.docx

A comprehensive H&P for patient Anne Smith is shown. Ms. Smith is a new patient presenting to an internal medicine office-based practice. Carly Sanders, an experienced nurse practitioner, authored the H&P.

Patient Name: Anne Smith Age: 55

Date of Visit: 2-14-2016 Gender: Female

Information Source: Patient, reliable source, face-to-face office visit

Subjective:

Chief Complaint: Follow up after Emergency Department visit

History of Present Illness: Reports were seen in the Emergency Department approximately 2 weeks ago and was treated for bronchitis with an unknown antibiotic that she has now finished. Was prescribed a refill of an Albuterol MDI as well. Pt continues to report cough and shortness of breath with exertion. Cough and shortness of breath have not improved since last Emergency Room visit. Cough reported as dry and present day and night without provocation. Has been using Albuterol MDI 4–5 times per day with slight relief of shortness of breath symptoms. Pt reports multiple diagnoses of bronchitis last year and has been using Albuterol MDI multiple times daily for the past 6 months or more.

PMH: Hypertension. Bronchitis. Hyperlipidemia. Obesity.

Medications: HTCZ 25mg BID. Albuterol MDI q4h PRN. Simvastatin 20mg daily. OTC Aleve 1–2 tabs PRN headaches.

Allergies: Codeine. Shellfish.

Family History: Mother and Father with CV disease. Son with asthma. Daughter with hypertension. Denies family history of DM. Mother diagnosed with breast cancer at age 40, died at 44.

Social History: Retired from clerical work. Widowed. Lives with adult children and assists with watching grandchildren. Denies tobacco use, ETOH use, drug use.

Review of Systems:

GENERAL: Reports good sleep but decreased energy levels. Denies fever.

CV: (-) palpitations. (-) CP. (-) swelling.

PULM: (+) SOB with exertion. (+) wheezing. (+) dry cough. (-) hemoptysis.

ENT: (-) rhinorrhea. (-) sinus pain/pressure. (-) ear pain/pressure. (-) sore throat.

Objective:

CV: RRR, no murmur.

Pulm : Posterior inspiratory wheezes bilaterally in all lobes. No rales/rhonchi/crackles. No consolidation present with percussion. Equal rise and fall of chest. No accessory muscle use.

Ears: Bilat TM pearly white, canals clear, no discharge, no external ear tenderness.

Nose: Nasal mucosa pink, moist. No discharge present. No sinus pressure pain.

Throat/Neck: Oral mucosa pink/moist. Tonsils grade 1 without exudate. No lymphadenopathy.

General: Obese caucasian female. Affect appropriate. Appears very anxious. Appropriately dressed. No obvious deformity.

VS: Temp 97.8, Pulse 72 RR 22, BP 140/90, BMI 32

Assessment:

1. Moderate persistent asthma with (acute) exacerbation

NURS 601B APRN Bridge course Week 7 Assignment Comprehensive H&P Case Study

2. Pneumonia, unspecified organism

3. Essential (primary) hypertension

4. Hyperlipidemia, unspecified

5. Obesity

Plan:

Dx Plan: None

Tx Plan: Rx: Qvar 40mcg/spray 2 puffs BID. Rx: Albuterol MDI 1-2puffs q4h PRN wheezing. Rx: Inhalation Spacer Device. Refill HTCZ 25mg PO BID #30 with 2 refills.

Also Check Out: NURS 601B APRN Bridge course Week 4 Assignment Meaningful Use for Nurses Paper

Refill Simvastatin 20mg PO QD #30 with 2 refills.

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ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.

Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.

One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.

I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.

In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.

Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).

Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).

Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.

I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.

As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.

It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Participation for MSN

Threaded Discussion Guiding Principles

The ideas and beliefs underpinning the threaded discussions (TDs) guide students through engaging dialogues as they achieve the desired learning outcomes/competencies associated with their course in a manner that empowers them to organize, integrate, apply and critically appraise their knowledge to their selected field of practice. The use of TDs provides students with opportunities to contribute level-appropriate knowledge and experience to the topic in a safe, caring, and fluid environment that models professional and social interaction. The TD’s ebb and flow is based upon the composition of student and faculty interaction in the quest for relevant scholarship. Participation in the TDs generates opportunities for students to actively engage in the written ideas of others by carefully reading, researching, reflecting, and responding to the contributions of their peers and course faculty. TDs foster the development of members into a community of learners as they share ideas and inquiries, consider perspectives that may be different from their own, and integrate knowledge from other disciplines.

Participation Guidelines

Each weekly threaded discussion is worth up to 25 points. Students must post a minimum of two times in each graded thread. The two posts in each individual thread must be on separate days. The student must provide an answer to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week. If the student does not provide an answer to each graded thread topic (not a response to a student peer) before the Wednesday deadline, 5 points are deducted for each discussion thread in which late entry occurs (up to a 10-point deduction for that week). Subsequent posts, including essential responses to peers, must occur by the Sunday deadline, 11:59 p.m. MT of each week.

Direct Quotes

Good writing calls for the limited use of direct quotes. Direct quotes in Threaded Discussions are to be limited to one short quotation (not to exceed 15 words). The quote must add substantively to the discussion. Points will be deducted under the Grammar, Syntax, APA category.

Grading Rubric Guidelines

Performance Category	10	9	8	4	0
Scholarliness Demonstrates achievement of scholarly inquiry for professional and academic decisions.	Provides relevant evidence of scholarly inquiry clearly stating how the evidence informed or changed professional or academic decisions Evaluates literature resources to develop a comprehensive analysis or synthesis. Uses valid, relevant, and reliable outside sources to contribute to the threaded discussion	Provides relevant evidence of scholarly inquiry but does not clearly state how the evidence informed or changed professional or academic decisions. Evaluates information from source(s) to develop a coherent analysis or synthesis. Uses some valid, relevant, reliable outside sources to contribute to the threaded discussion.	Discusses using scholarly inquiry but does not state how scholarly inquiry informed or changed professional or academic decisions. Information is taken from source(s) with some interpretation/evaluation, but not enough to develop a coherent analysis or synthesis. Little valid, relevant, or reliable outside sources are used to contribute to the threaded discussion. Demonstrates little or no understanding of the topic.	Discusses using scholarly inquiry but does not state how scholarly inquiry informed or changed professional or academic decisions. Information is taken from source(s) without any interpretation/evaluation. The posting uses information that is not valid, relevant, or reliable	No evidence of the use of scholarly inquiry to inform or change professional or academic decisions. Information is not valid, relevant, or reliable
Performance Category	10	9	8	4	0
Application of Course Knowledge – Demonstrate the ability to analyze, synthesize, and/or apply principles and concepts learned in the course lesson and outside readings and relate them to real-life professional situations	Posts make direct reference to concepts discussed in the lesson or drawn from relevant outside sources; Applies concepts to personal experience in the professional setting and or relevant application to real life.	Posts make direct reference to concepts discussed in the lesson or drawn from relevant outside sources. Applies concepts to personal experience in their professional setting and or relevant application to real life Interactions with classmates are relevant to the discussion topic but do not make direct reference to lesson content	Posts are generally on topic but do not build knowledge by incorporating concepts and principles from the lesson. Does not attempt to apply lesson concepts to personal experience in their professional setting and or relevant application to real life Does not demonstrate a solid understanding of the principles and concepts presented in the lesson	Posts do not adequately address the question posed either by the discussion prompt or the instructor’s launch post. Posts are superficial and do not reflect an understanding of the lesson content Does not attempt to apply lesson concepts to personal experience in their professional setting and or relevant application to real life	Posts are not related to the topics provided by the discussion prompt or by the instructor; attempts by the instructor to redirect the student are ignored No discussion of lesson concepts to personal experience in the professional setting and or relevant application to real life
Performance Category	5	4	3	2	0
Interactive Dialogue Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts a minimum of two times in each graded thread, on separate days. (5 points possible per graded thread)	Exceeds minimum post requirements Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts three or more times in each graded thread, over three separate days. Replies to a post posed by faculty and to a peer Summarizes what was learned from the lesson, readings, and other student posts for the week.	Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts a minimum of two times in each graded thread, on separate days Replies to a question posed by a peer Summarizes what was learned from the lesson, readings, and other student posts for the week.	Meets expectations of 2 posts on 2 different days. The main post is not made by the Wednesday deadline Does not reply to a question posed by a peer or faculty	Has only one post for the week Discussion posts contain few, if any, new ideas or applications; often are a rehashing or summary of other students’ comments	Does not post to the thread No connections are made to the topic
	Minus 1 Point	Minus 2 Point	Minus 3 Point	Minus 4 Point	Minus 5 Point
Grammar, Syntax, APA Note: if there are only a few errors in these criteria, please note this for the student in as an area for improvement. If the student does not make the needed corrections in upcoming weeks, then points should be deducted. Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition	2-3 errors in APA format. Written responses have 2-3 grammatical, spelling, and punctuation errors. Writing style is generally clear, focused, and facilitates communication.	4-5 errors in APA format. Writing responses have 4-5 grammatical, spelling and punctuation errors. Writing style is somewhat focused.	6-7 errors in APA format. Writing responses have 6-7 grammatical, spelling and punctuation errors. Writing style is slightly focused making discussion difficult to understand.	8-10 errors in APA format. Writing responses have 8-10 grammatical, spelling and punctuation errors. Writing style is not focused, making discussion difficult to understand.	Post contains greater than 10 errors in APA format. Written responses have more than 10 grammatical, spelling and punctuation errors. Writing style does not facilitate communication. The student continues to make repeated mistakes in any of the above areas after written correction by the instructor
	0 points lost				-5 points lost
Total Participation Requirements per discussion thread	The student answers the threaded discussion question or topic on one day and posts a second response on another day.				The student does not meet the minimum requirement of two postings on two different days
Early Participation Requirement per discussion thread	The student must provide a substantive answer to the graded discussion question(s) or topic(s), posted by the course instructor (not a response to a peer), by Wednesday, 11:59 p.m. MT of each week.				The student does not meet the requirement of a substantive response to the stated question or topic by Wednesday at 11:59 pm MT.

NOTE: To receive credit for a week’s discussion, students may begin posting no earlier than the Sunday immediately before each week opens. Unless otherwise specified, access to most weeks begins on Sunday at 12:01 a.m. MT, and that week’s assignments are due by the next Sunday by 11:59 p.m. MT. Week 8 opens at 12:01 a.m. MT Sunday and closes at 11:59 p.m. MT Wednesday. Any assignments and all discussion requirements must be completed by 11:59 p.m. MT Wednesday of the eighth week.

NURS 601B APRN Bridge course Week 7 Assignment Comprehensive H&P Case Study