Complex patient care cases.

The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.

1. Select a patient encounter from your current clinical experience.

2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.

You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.

3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.

Below is the overview of the required elements for this assignment:

*Title Page (Page 1): Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.

*Subjective (Start of Page 2): Follow APA guidelines for running head on page 2 and subsequent pages.

CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.

HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]

PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.

Allergies: State the offending medication/food and the reactions.

Medications: Names, dosages, and routes of administration.

Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.

Click on the link below to explore the CDC’s information on the ‘social determinants of health’. https://www.cdc.gov/socialdeterminants/

Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.

Health Maintenance/Promotion: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.

Click on the link below to access information about current guidelines.https://www.uspreventiveservicestaskforce.org/

Review of Systems (ROS): this is to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness. You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/categories applicable to your patient’s chief complaint.

General: May include if patient has had a fever, chills, fatigue, malaise, etc.

Skin:

HEENT: head, eyes, ears, nose and throat

Neck:

CV: cardiovascular

Lungs:

GI: gastrointestinal

GU: genito-urinary

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological

Endo: endocrine

Psych:

*Objective: 

Physical Examination (PE): either limited for a focused exam or more extensive for a complete history and physical assessment. This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs. While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint. Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.

VS: vital signs, height and weight, BMI

Gen: general statement of appearance, if there is any acute distress.

Skin:

HEENT: head, eyes, ears, nose and throat

Neck:

CV: cardiovascular

Lungs:

Abd: abdomen

GU: genito-urinary

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological exam

Psych:

Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).

*Assessment: (number each diagnosis)

Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis. A statement of current condition of all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the S and O must support this diagnosis. Pertinent positives and negatives must be found in the write-up.

*Plan: (number each plan specific to each diagnosis)

These are the interventions that relate to the above diagnosis and address the following aspects (they should be separated out as listed below):

Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.

Therapeutic: changes in meds, skin care, counseling

Educational: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.

Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.

*Clinical Decision Making 

The next section summarizes your critical thinking, decision-making and diagnostic reasoning skills that provides you the platform to expand on your identified Typhon patient encounter. It is a reflection of the thought process you used in caring for the patient. Follow the directions under each section and label each area as appropriate. All information should be in your own words.

Pathophysiology:

Include information in regard to the pathophysiology related to the main diagnosis or illness process. This will help to understand how the S and O supported the diagnosis you assigned.

Do not copy and paste from credible sources. Paraphrase source information as you construct your discussion of the pathophysiology and ensure that you provide in-text and reference citations for the source.