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
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.
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.
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
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.
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.