Episodic Visit: Gastrointestinal Focused Note For this Assignment, you will work with a patient with a gastrointestinal condition that you examined during the last three weeks. You will complete your second Episodic/Focused

Episodic Visit: Gastrointestinal Focused Note

For this Assignment, you will work with a patient with a gastrointestinal condition that you examined during the last three weeks. You will complete your second Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, PMH, socioeconomic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

 

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

To prepare:

·        Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this Assignment.

·        Select a patient that you examined during the last three weeks based on any gastrointestinal conditions. With this patient in mind, address the following in a Focused Note:

Assignment:

·        Subjective: What details did the patient provide regarding her personal and medical history?

·        Objective: What observations did you make during the physical assessment?

·        Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

·        Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

·        Reflection notes: What would you do differently in a similar patient evaluation?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 6.

By Day 7

Submit your Episodic/Focused Note Assignment. (Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6.)

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area. 

1.     To submit your completed assignment, save your Assignment as WK6Assgn2_LastName_Firstinitial

2.     Then, click on Start Assignment near the top of the page.

3.     Next, click on Upload File and select Submit Assignment for review.

Rubric

PRAC_6531_Week6_Assignment2_Rubric

PRAC_6531_Week6_Assignment2_Rubric

Criteria

Ratings

Pts

This criterion is linked to a
Learning Outcome
Organization of Write-up

10 to >6.0 pts

Excellent

All information organized in logical sequence; follows acceptable
format and utilizes expected headings.

6 to >3.0 pts

Good

Information generally organized in logical sequence; follows
acceptable format and utilizes expected headings.

3 to >0.0 pts

Fair

Errors in format; information intermittently organized. Headings are
used some of the time.

0 pts

Poor

Errors in format; information disorganized. Headings are not used
appropriately.

10 pts

This criterion is linked to a
Learning Outcome
Thoroughness of History

20 to >15.0 pts

Excellent

Thoroughly documents all pertinent history components for type of
note; includes critical as well as supportive information.

15 to >11.0 pts

Good

Documents most pertinent examination components.

11 to >7.0 pts

Fair

Documents some pertinent examination components.

7 to >0 pts

Poor

Physical examination cursory; misses several pertinent components.

20 pts

This criterion is linked to a
Learning Outcome
History of Present Illness

10 to >6.0 pts

Excellent

Thoroughly documents all 8 aspects of HPI and pertinent other data
relevant to chief complaint. Includes critical as well as supportive
information.

6 to >4.0 pts

Good

Documents at least 6 aspects of the HPI and pertinent other data
relevant to chief complaint. Includes critical information.

4 to >2.0 pts

Fair

Documents at least 4 aspects of HPI and some data pertinent to chief
complaint. Lacks some critical information or rambling in history.

2 to >0 pts

Poor

Missing many aspects of HPI and pertinent data. Critical information
missing.

10 pts

This criterion is linked to a
Learning Outcome
Thoroughness of Physical Exam

10 to >7.0 pts

Excellent

Thoroughly documents all pertinent examination components for type of
note.

7 to >4.0 pts

Good

Documents most pertinent examination components.

4 to >2.0 pts

Fair

Documents some pertinent examination components.

2 to >0 pts

Poor

Physical examination cursory; misses several pertinent components.

10 pts

This criterion is linked to a
Learning Outcome
Diagnostic Reasoning

10 to >7.0 pts

Excellent

Assessment consistent with prior documentation. Clear justification
for diagnosis. Notes all secondary problems. Cost effective when ordering
diagnostic tests.

7 to >4.0 pts

Good

Assessment consistent with prior documentation. Clear justification
for diagnosis. Notes most secondary problems.

4 to >2.0 pts

Fair

Assessment mostly consistent with prior documentation. Fails to
clearly justify diagnosis or note secondary problems or orders
inappropriate diagnostic tests.

2 to >0 pts

Poor

Assessment not consistent with prior documentation. Fails to clearly
justify diagnosis or note secondary problems or orders inappropriate diagnostic
tests.

10 pts

This criterion is linked to a
Learning Outcome
Treatment Plan/Patient Education

20 to >15.0 pts

Excellent

Treatment plan addresses all issues raised by diagnoses, excellent
insight into patient’s needs. Medications prescribed are appropriate and
full prescription is included. Evidence based decisions. Cost effective
treatment.

15 to >10.0 pts

Good

Treatment plan addresses most issues raised by diagnoses. Medications
prescribed are appropriate but include 1 or 2 error in writing prescription.

10 to >5.0 pts

Fair

Treatment plan fails to address most issues raised by diagnoses.
Medications are inappropriate or include 3 or more errors in writing
prescription.

5 to >0 pts

Poor

Minimal treatment plan addressed. Medications are inappropriate or
poorly written prescription.

20 pts

This criterion is linked to a
Learning Outcome
Patient Education / Follow Up / Reflection

10 to >8.0 pts

Excellent

Patient education addresses all issues raised by diagnoses, excellent
insight into patient’s needs. Follow up plan in appropriate and reflects
acuity of illness. Reflection is thoughtful and in depth.

8 to >5.0 pts

Good

Patient education addresses most issues raised by diagnoses. Follow
up plan is appropriate but lacks specifics Reflection is thoughtful and in
depth.

5 to >3.0 pts

Fair

Patient education fails to address most issues raised by diagnoses.
Follow up plan is lacking specifics or is inappropriate for patient acuity.
Reflection is brief, vague. and does not discuss anything that would have
been done in addition to or differently.

3 to >0 pts

Poor

Minimal patient education addressed. Follow up plan is inappropriate
Reflection is absent.

10 pts

This criterion is linked to a
Learning Outcome
Written Expression and Formatting English writing standards: Correct
grammar, mechanics, and proper punctuation. Professional language utilized

5 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.
Professional language utilized.

4 pts

Good

Contains a few (1-2) grammar, spelling, and punctuation errors.
Contains a few errors (1 or 2) in professional language use.

2 pts

Fair

Contains several (3-4) grammar, spelling, and punctuation errors.
Contains several errors (3 -4) in professional language use.

0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that
interfere with the reader’s understanding. Contains many errors in
professional language use.

5 pts

This criterion is linked to a
Learning Outcome
Scholarly References and Clinical Practice Guidelines. The assignment
includes a minimum of 3 scholarly references that are not older than 5 years.
Clinical practice guidelines are included if applicable.

5 pts

Excellent

Contains parenthetical/in-text citations and at least 3 evidenced
based references less than 5 years old are listed. Clinical practice
guidelines are cited if applicable.

4 pts

Good

Contains parenthetical/in-text citations and at least 2 evidenced
based references less than 5 years old are listed. Clinical practice
guidelines are cited if applicable.

2 pts

Fair

Contains parenthetical/in-text citations and at least 1 evidenced
based reference less than 5 years old is listed. Clinical practice
guidelines are not cited if applicable.

0 pts

Poor

Contains no parenthetical/in-text citations and 0 evidenced based
references listed. Clinical practice guidelines are not cited if
applicable.

5 pts

Total Points: 100

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