SOAP Note Assignment

Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.

Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.

Download the access codes.

Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.  If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.

In your practice as a nurse, you may use procedures and methods that did not necessarily originate in evidence, but instead were derived from informal and unwritten conventions, traditions, and observations. While these techniques may have merit, practices are constantly being updated and contradicted by information from scholarly research studies and professional guidelines. This new information serves as “evidence” for revising practices to improve outcomes across health care.

Based on this evidence, you can formulate a question. In this Discussion, you consider the use of evidence-based practice in your own organization and formulate a question that you will need to answer for your portfolio project. This is called a PICOT question. You will also investigate strategies for overcoming barriers to implementing evidence-based practice (EBP).

To prepare:

• Consider a recent clinical experience in which you were      providing care for a patient.
• Determine the extent to which the care that you      provided was based on evidence and research findings or supported only by      your organization’s standard procedures. How do you know if the tasks were      based on research?
• What questions have you thought about in a particular      area of care such as a procedure or policy?
• Review Chapter 2, pages 31–34 on “Asking Well worded      Clinical Questions” in Polit & Beck and consult the resource from the      Walden Student Center for Success: Clinical Question Anatomy & examples      of PICOT questions (found in this week’s Learning Resources). Formulate      your background questions and PICOT question.
• Reflect on the barriers that might inhibit the      implementation of evidence-based practice in your clinical environment.
• Review the article “Adopting Evidence-Based Practice in      Clinical Decision Making” in this week’s Learning Resources. Select one of      the barriers described that is evident in your organization and formulate      a plan for overcoming this barrier.

Post an evaluation of the use, or lack thereof, of EBP in a recent clinical experience. Identify which aspects of the care delivered, if any, were based on evidence and provide your rationale. List your background questions and PICOT question about this nursing topic. Critique how the policies, procedures, and culture in your organization may hinder or support the adoption of evidence-based practices. Identify the barrier you selected from the article and explain how this barrier could be overcome within your organization.

Your quest to purchase a new car begins with an identification of the factors important to you. As you conduct a search of cars that rate high on those factors, you collect evidence and try to understand the extent of that evidence. A report that suggests a certain make and model of automobile has high mileage is encouraging. But who produced that report? How valid is it? How was the data collected, and what was the sample size?

In this Assignment, you will delve deeper into clinical inquiry by closely examining your PICO(T) question. You also begin to analyze the evidence you have collected.

To Prepare:

• Review the Resources and identify a clinical issue of interest that can form the basis of a clinical inquiry.
• Develop a PICO(T) question to address the clinical issue of interest for the Assignment.
• Use the key words from the PICO(T) question you developed and search at least four different databases in the Walden Library. Identify at least four relevant systematic reviews or other filtered high-level evidence, which includes meta-analyses, critically-appraised topics (evidence syntheses), critically-appraised individual articles (article synopses). The evidence will not necessarily address all the elements of your PICO(T) question, so select the most important concepts to search and find the best evidence available.
• Reflect on the process of creating a PICO(T) question and searching for peer-reviewed research.

The Assignment (Evidence-Based Project)

Part 3: Advanced Levels of Clinical Inquiry and Systematic Reviews

Create a 6- to 7-slide PowerPoint presentation in which you do the following:

• Identify and briefly describe your chosen clinical issue of interest.
• Describe how you developed a PICO(T) question focused on your chosen clinical issue of interest.
• Identify the four research databases that you used to conduct your search for the peer-reviewed articles you selected.
• Provide APA citations of the four peer-reviewed articles you selected.
• Describe the levels of evidence in each of the four peer-reviewed articles you selected, including an explanation of the strengths of using systematic reviews for clinical research. Be specific and provide examples.

Minimum of 250 words with peer review reference

 

Discuss how evidence-based practice is defined as translational research. Describe the framework that supports that definition. Identify a population health issue you are interested in researching and discuss the issue using that framework. As you select an issue, remember you will be building upon your research in this course for your evidence-based practice project in the next course. Think about how you can focus your research now to help you complete your EBP project.

Note: While you will only be proposing a solution and implementation plan in your EBP project, keep in mind EBP projects lay a foundation for doctoral research, since doctoral candidates have the opportunity to actually implement their projects. If you are interested in pursuing doctoral education, it is a good idea to choose an issue you would be interested in pursuing in greater depth. The research and work you complete on your EBP project now can be used if you choose to move forward into doctoral education.

Week 3: Shared Governance and the Magnet Model

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Describe the nursing care delivery model used at your current or previous employer. Would you utilize this model at SLMC? Discuss current interprofessional collaboration and how you would encourage collaborative efforts. Does the model support the person-centred nursing framework by McCormack and McCance (2017)? Explain your rationale for choosing to use or not use the person-centred nursing framework.

Please refer back to the 2017 PCNF overview presented below.

Patient-Centered Care: A Person-Centred Care Model Revisited

Caring continues to be a central concept in nursing; however, the context for caring is transforming, resulting in conceptual and theoretical advancements related to the evolving healthcare practice settings. McCormack and McCance originally developed a Person-Centred Nursing (PCN) Framework in 2006 and updated it in 2010 that can be applied to practice in complex healthcare systems (McCormack & McCance, 2006; McCormack & McCance, 2017). The PCN Framework provides a standard of care for practice and is a multidimensional process that places emphasis on the person as the center of care delivery (McCance, McCormack, & Dewing, 2011). The PCN Framework fosters outcomes related to therapeutic relationships through respecting individuals as persons and partners in care. The Person-Centred Care Nursing Framework consists of four constructs: prerequisites, the care environment, person-centred processes, and outcomes (McCance et al., 2011). To deliver effective care, one must work from the outer circle first to the core. McCormack, B. & McCance, T. (2017)Prerequisites focus on the attributes of the nurses and include being professionally competent, having developed interpersonal skills, being committed to the job, being able to demonstrate clarity of beliefs and values, and knowing self. The care environment focuses on the context in which care is delivered and includes appropriate skill mix, systems that facilitate shared decision making, effective staff relationships, organizational systems that are supportive, the sharing of power, the potential for innovation and risk taking, and the physical environment. Person-centred processes focus on delivering care through a range of activities and include working with a patient’s beliefs and values to overcome this gap between the concept and the reality of person-centred care we have developed the Person-Centred Nursing Framework…engagement, having sympathetic presence, sharing decision making, and providing holistic care. Outcomes, the central component of the Framework, are the results of effective, person-centred nursing and include: satisfaction with care, involvement in care, feeling of well-being, and creating a therapeutic environment. (McCance, McCormack, & Dewing, 2011).

                                                                                 McCormack, B. & McCance, T. (2017)

Reference

McCormack, B. & McCance, T. (2017). Person-centered practice in nursing and health care. Theory and practice (2nd ed.). Oxford: Wiley Blackwell.