14 Jan National guidelines, inclu

The assignment is a paper which is to be written in APA format. This includes a title page and reference page.

Review the attached patient visit information. The patient has presented for an acute care visit. You are provided with the subjective and objective exam findings. As the provider, you are to diagnose and develop the management plan for this case study patient.

Use the categories below to create section headings for your paper.

Introduction: briefly discuss the purpose of this paper.

Assessment: review the provided case study information.

Identify the primary, secondary and differential diagnoses for the patient. Use the 601 SOAP note format as a guide to develop your diagnoses.

Each diagnosis will include the following information:

1. ICD 10 code.

2. A brief pathophysiology statement which his no longer that 2 sentences, paraphrased and includes common signs and symptoms of the diagnosis.

3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentence statement which links the subjective and objective findings (including lab data and interpretation).

4. A rationale statement which summarizes why the diagnosis was chosen.

5. Do not include quotes, paraphrase all scholarly information and provide an intext citation to your scholarly reference. Use the Reference Guidelines document for information on scholarly references.

Plan (there are five (5) sections to the management plan)

1. Diagnostics. List all labs and diagnostic test you would like to order. Each test includes a rationale statement which includes the diagnosis for the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited.

2. Medications: Each medication is listed in prescription format. Each prescribed and OTC medication is linked to a specific diagnosis and includes a paraphrased EBP rationale for prescribing.

3. Education: section includes detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized exercise recommendations and warning sign for diagnosis and medications if applicable. All education steps are linked to a diagnosis, paraphrased, and include a paraphrased EBP rationale. Review the NR601 SOAP note guideline for more detailed information.

4. Referrals: any recommended referrals are appropriate to the patient diagnosis and current condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering

5. Follow up: Follow up includes a specific time frame to return to PCP office for next scheduled appointment. Includes EBP rationale with in text citation.

Medication costs: in this section students will research the costs of all prescribed monthly medications. Students may use Good Rx, Epocrates or another resource (can use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice.

SOAP note: A focused SOAP note, written on a separate page, follows the assignment. The SOAP note is written following the provided SOAP note format.

· The subjective section is organized to follow the SOAP note format. The ROS is focused, only pertinent body systems are included.

· The objective section is maintained as written, no additional information is added.

· The assessment section includes only the diagnoses and ICD 10 codes. Diagnosed are labeled as primary, secondary or differential diagnoses. Rationale is not required.

· The plan includes 5 sections. Rationale is not required.

The assignment will be submitted through TurnItIn.

Category

Points

%

Description

Assessment

50

25

Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. A one to two sentence paraphrased pathophysiology statement explains the diagnosis. Include pertinent positive and negative findings to support your diagnoses from the history and physical exam which links this diagnosis to your patient. Each diagnoses must include an intext citation to a scholarly reference.

Evidence-Based Practice (EBP)

50

25

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used as rationale to support the diagnosis and develop the management plan. Every diagnoses must include an intext citation to a scholarly reference. Each action step or order within all plan sections includes an intext citation to an appropriate reference as listed in the Reference Guidelines document.

Plan: diagnostics

10