Worldview and Nursing Process Personal Statement

Worldview and Nursing Process Personal Statement
Worldview and Nursing Process Personal Statement
Description of my personal worldview
My personal worldview are the principles that guide my decisions and life. They allow me to make sense of my life and world, as well as determine how I perceive my reality. In addition, they guide my ethical and moral beliefs and actions while allowing me to integrate cultural, religious and spiritual elements to respond meaningfully to the challenges and opportunities I face in life (Grinspun & Bajnok, 2018). My worldview as a Christian is that I was created by God and…
Being able to articulate your personal worldview can help you formulate a personal philosophy of practice and enhance your influence on patients and the industry. In this assignment, you will have an opportunity to reflect on your current and future practice, and the ways worldview and nursing theory influence that practice. Worldview and Nursing Process Personal Statement
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Draft a 1,000-1,250 word paper in which you:
Describe your personal worldview, including the religious, spiritual, and cultural elements that you think most influence your personal philosophy of practice and attitude towards patient care.

Choose a specific nursing theory that is most in line with your personal philosophy of practice and approach to patient care and discuss the similarities. Explain how the nursing theory reinforces your approach to care.

Include in your explanation a specific example of a past or current practice and how your worldview and the nursing theory could assist you in resolving this issue. Worldview and Nursing Process Personal Statement

Finally, explain how your worldview and the nursing theory will assist you in further developing your future practice.

You are required to cite five to 10 sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. Worldview and Nursing Process Personal Statement
You are required to submit this assignment to Lopes Write. Please refer to the directions in the Student Success Center.
 
Worldview and Nursing Process Personal Statement 

 
1

Unsatisfactory

0.00%
2

Less than Satisfactory

80.00%
3

Satisfactory

88.00%
4

Good

92.00%
5

Excellent

100.00%

70.0 %Content
 

20.0 %Personal Worldview, Including the Religious, Spiritual, and Cultural Elements That Most Influence Personal Philosophy of Practice and Attitude Towards Patient Care
A discussion of personal worldview, including the religious, spiritual, and cultural elements that most influence personal philosophy of practice and attitude towards patient care is not included.
A discussion of personal worldview, including the religious, spiritual, and cultural elements that most influence personal philosophy of practice and attitude towards patient care is present, but it lacks detail or is incomplete.
A discussion of personal worldview, including the religious, spiritual, and cultural elements that most influence personal philosophy of practice and attitude towards patient care is present.
Worldview and Nursing Process Personal Statement
A discussion of personal worldview, including the religious, spiritual, and cultural elements that most influence personal philosophy of practice and attitude towards patient care is clearly provided and well developed.
A comprehensive discussion of personal worldview, including the religious, spiritual, and cultural elements that most influence personal philosophy of practice and attitude towards patient care is thoroughly developed with supporting details.

15.0 %Specific Nursing Theory in Line With the Personal Philosophy of Practice and Approach to Patient Care, Including Similarities and How the Nursing Theory Reinforces the Approach to Care
A discussion of a specific nursing theory in line with the personal philosophy of practice and approach to patient care, including similarities and how the nursing theory reinforces the approach to care, is not included.
Worldview and Nursing Process Personal Statement
A discussion of a specific nursing theory in line with the personal philosophy of practice and approach to patient care, including similarities and how the nursing theory reinforces the approach to care, is present, but it lacks detail or is incomplete.
A discussion of a specific nursing theory in line with the personal philosophy of practice and approach to patient care, including similarities and how the nursing theory reinforces the approach to care, is present.
A discussion of a specific nursing theory in line with the personal philosophy of practice and approach to patient care, including similarities and how the nursing theory reinforces the approach to care, is clearly provided and well developed.
A comprehensive discussion of a specific nursing theory in line with the personal philosophy of practice and approach to patient care, including similarities and how the nursing theory reinforces the approach to care, is thoroughly developed with supporting details.

15.0 %Specific Example of a Past or Current Practice Problem and How Worldview and the Nursing Theory Could Assist in Resolving This Issue
A discussion of a specific example of a past or current practice problem and how worldview and the nursing theory could assist in resolving this issue is not included.
A discussion of a specific example of a past or current practice problem and how worldview and the nursing theory could assist in resolving this issue is present, but it lacks detail or is incomplete.
A discussion of a specific example of a past or current practice problem and how worldview and the nursing theory could assist in resolving this issue is present.
A discussion of a specific example of a past or current practice problem and how worldview and the nursing theory could assist in resolving this issue is clearly provided and well developed.
A comprehensive discussion of a specific example of a past or current practice problem and how worldview and the nursing theory could assist in resolving this issue is thoroughly developed with supporting details.

15.0 %How Worldview and the Nursing Theory Will Assist in Further Developing Future Practice
A discussion of how worldview and the nursing theory will assist in further developing future practice is not included.
A discussion of how worldview and the nursing theory will assist in further developing future practice is present, but it lacks detail or is incomplete.
A discussion of how worldview and the nursing theory will assist in further developing future practice is present.
Worldview and Nursing Process Personal Statement
A discussion of how worldview and the nursing theory will assist in further developing future practice is clearly provided and well developed.
A comprehensive discussion of how worldview and the nursing theory will assist in further developing future practice is thoroughly developed with supporting details.

5.0 %Required Sources
Sources are not included.
Number of required sources is only partially met.
Number of required sources is met, but sources are outdated or inappropriate.
Number of required sources is met. Sources are current, but not all sources are appropriate for the assignment criteria and nursing content.
Number of required resources is met. Sources are current, and appropriate for the assignment criteria and nursing content.

20.0 %Organization and Effectiveness
 

7.0 %Thesis Development and Purpose
Paper lacks any discernible overall purpose or organizing claim.
Thesis is insufficiently developed or vague. Purpose is not clear.
Thesis is apparent and appropriate to purpose.
Worldview and Nursing Process Personal Statement
Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.
Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

8.0 %Argument Logic and Construction
Worldview and Nursing Process Personal Statement
Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.
Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.
Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.
Argument shows logical progressions. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.
Clear and convincing argument that presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

5.0 %Mechanics of Writing (includes spelling, punctuation, grammar, language use)
Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.
Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.
Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.
Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.
Writer is clearly in command of standard, written, academic English.

10.0 %Format
 

5.0 %Paper Format (Use of appropriate style for the major and assignment)
Template is not used appropriately or documentation format is rarely followed correctly.
Template is used, but some elements are missing or mistaken; lack of control with formatting is apparent.
Template is used, and formatting is correct, although some minor errors may be present.
Template is fully used; There are virtually no errors in formatting style.
All format elements are correct.
Worldview and Nursing Process Personal Statement

5.0 %Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)
Sources are not documented.
Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.
Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.
Sources are documented, as appropriate to assignment and style, and format is mostly correct.
Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

100 %Total Weightage
Worldview and Nursing Process Personal Statement

 
Worldview and nursing process personal statement
Description of my personal worldview
My personal worldview are the principles that guide my decisions and life. They allow me to make sense of my life and world, as well as determine how I perceive my reality. In addition, they guide my ethical and moral beliefs and actions while allowing me to integrate cultural, religious and spiritual elements to respond meaningfully to the challenges and opportunities I face in life (Grinspun & Bajnok, 2018) Worldview and Nursing Process Personal Statement. My worldview as a Christian is that I was created by God and exist to do his service. I believe in the absolute truth that God is the Almighty Creator who has dominion over everything and is all knowing. God defines the world through purity and creativity, and allows humans to exercise freewheel that includes making mistakes for which each personnel will be punished on the Day of Judgment. God created everything that includes humans who are on earth to serve a specific function: serving God. For as long as humans are alive, they must serve God since they will be judged for their actions upon death. The judgment follows a fair reward and punishment system that is based on God’s Ten Commandments as presented in Exodus 20. These commandments have clear prohibitions on the absolute actions that humans can or cannot be participants. For instance, there is a prohibition against killing with the implication that all killers will be judged and punished. Since I believe in God as presented in the Christian religion, I understand that I should spend my life in service to God and observing the Ten Commandments. In this respect, I ascribe to the Christian worldview that the bible offers all the instructions as to how humans should ideally live their lives. Worldview and Nursing Process Personal Statement.
I understand that I am not a divine being, and as such I am subject to making mistakes. Even with the clear instructions in the bible, I still occasionally make mistakes and would be considered a sinner. However, I try as much as possible to follow God’s instructions and seek forgiveness for mu mistakes. In addition, I try not to intentionally make any mistakes. As a Christian, I look at the bible as the foundation of my life and guide for my actions. Still, I must concede that I am influenced by my environment, particularly the established societal norms. For instance, the Ten Commandments prohibits killing. Nonetheless, as a nurse, I concede that euthanasia makes sense and there are people who experience so much suffering that death acts as a relief for them and the people around them. This implies that although the bible is my foundation, I am influenced by the elements around me and try to make informed decisions that reduce the possibility of conflict. Interactions with my environment have secularized my perception of history, politics, law, science, man and God Worldview and Nursing Process Personal Statement. I must concede that it is not uncommon for me to experience conflicts between what the bible instructs me to do and what the society expects of me. Still, I typically try to pick decisions that produce the least disruptions to my life. These conflicts (between biblical and environmental influences) act as the basis for all the ethical conflicts I experience such as when facing same-gender marriage, cloning, abortion and stem-cell research subjects. In this respect, my worldview is influenced by the bible and my environment with a focus on trying to lead a Christian life. This worldview has influenced how I perceive my workplace and when providing nursing services, helping in developing standards that help me make decisions that I can live with. Worldview and Nursing Process Personal Statement.
Nursing theory in line with personal worldview
I believe that the Theory of Human Caring as presented by Jean Watson best aligns with my personal worldview. As a Christian, I believe that my life should be in service to God. Although I have not been blessed to directly serve God as part of the clergy, I can fulfil the expectation of service through engaging patients in offering nursing services. The theory advances that caring is a core requirement for successful nurses since it guides them in displaying kindness and concern for patients while always trying to achieve the best care results Worldview and Nursing Process Personal Statement. Patients represent a vulnerable group who expect that the nurses will always act in their best interest. Through having a caring mentality and personality, I am motivated to provide the best possible services to my patients (Butts & Karen, 2018; Huff, Kline & Peterson, 2015) Worldview and Nursing Process Personal Statement.
I am particularly guided by the ten curative factors offered in the theory. The first curative factor is the capacity to embrace my patients so that they feel I have altruistic motives for engaging them and providing care. This helps with the patients’ attitudes and response to treatment. The second factor is being inspired to offer the care that patients truly require. The third factor is nurturing trusting, caring and helping relationships. The fourth factor is engendering trust through cultural sensitive and acknowledging individual beliefs. The fifth factor is practicing forgiveness with a focus on always improving even as mistakes are corrected Worldview and Nursing Process Personal Statement. The sixth factor is integrating current evidence to improve professional practice. The seventh factor is pursuing a balance between addressing personal needs and the needs of others. The eighth factor is co-creating a healing environment that respects human dignity. The ninth factor is ministering to the basic physical, spiritual and emotional needs of patients. The final factor is being open to possibilities beyond the realms of science since science does not have answers to everything (Butts & Karen, 2018). Worldview and Nursing Process Personal Statement.
How worldview and nursing theory will help in developing future practice
Watson’s Theory of Human Caring is well aligned with my worldview as a Christian and will help me in developing future practice as a nurse. They have made me more tolerant and open to the idea that I do not have all the answers. Even as I provide professional nursing services, I understand that my capacity to provide services is limited by circumstances, expectations, knowledge and other environmental influences. As a human, I believe that every person should be respected and treated with dignity. We should treat others with the same level of respect and dignity as we would like to be treated under the same circumstance. I understand that interpersonal interactions are important within the nursing care environment such that healing becomes incidental as caring takes on a central position. Through caring for my patients, I will always strive to provide the best possible care thereby guarantees the best possible care outcomes thus advancing the Christian expectation of living as God instructed (Stanhope & Lancaster, 2014). Worldview and Nursing Process Personal Statement.
My theory and worldview allow me to make a difference in my community, enabling me to make rational and ethical decisions. They help me in affirming and safeguarding humanity as God’s creation. In addition, they allow me to live an authentic life through unveiling my thoughts, attitudes and feelings. I have a caring personality, and along with my Christian worldview, I feel that the theory has helped in affirming my decision to pursue a nursing career. The combination of these elements have helped me feel that my career is fulfilling (Cherry & Jacob, 2013). Also, they have made me determined to gain greater influence to pursue policy changes. I will gain influence through experience and education. Experience will allow me to gain familiarity with nursing concepts, especially how to make the best decisions that reduce the possibility of conflict between my beliefs and what the society expects of me. Education will introduce me to new nursing concepts that allow me to better meet the needs of my patients and the community (Iwasiw, Andrusyszyn & Goldenberg, 2019). Overall, my worldview and the nursing theory have affirmed my belief that nursing is the best career choice for me, and they make me determined to advance my career within the profession. Worldview and Nursing Process Personal Statement
References
Butts, J. & Karen (2018). Philosophies and theories for advance nursing practice (3rd ed.). Burlington, MA: Jones & Bartlett Learning.
Cherry, B. & Jacob, S. (2013). Contemporary nursing, issues, trends, & management (6th ed.). Amsterdam: Elsevier Health Sciences.
Grinspun, D. & Bajnok, I. (2018). Transforming nursing through knowledge: best practices for guideline development, implementation science, and evaluation. Indianapolis, IN: Sigma Theta Tau International.
Huff, R., Kline, M. & Peterson, D. (2015). Health promotion in multicultural populations: a handbook for practitioners and students (3rd ed.). Thousand Oaks, CA: SAGE Publications, Inc. Worldview and Nursing Process Personal Statement
Iwasiw, C., Andrusyszyn, M. & Goldenberg, D. (2019). Curriculum development in nursing education (4th ed.). Burlington, MA: Jones & Bartlett.
Stanhope, M. & Lancaster, J. (2014). Public health nursing: population-centered health care in the community (8th ed.). Maryland Heights, MO: Elsevier/Mosby. Worldview and Nursing Process Personal Statement


ADHD SOAP Note example

ADHD SOAP Note example
ADHD SOAP Note example
SOAP Note for Attention-Deficit/ Hyperactivity Disorder (ADHD) in an 8 Year-Old Caucasian Boy
Patient: A.F.                Age: 8             Gender: Male              Race: Caucasian
SUBJECTIVE
CC: The mother to the eight-year old boy states that her son has been displaying abnormal behavior in that he is continually moving around and is unable to concentrate for long on any task. She has also received reports from school that the boy is excessively disruptive and cannot finish work given to him by the teachers.
HPI: The patient is an 8 year-old Caucasian male child with hyperactivity, inattention, and impulsivity that started one month ago and is becoming more intense. It is not associated with a lack of understanding instructions on the part of the child. The mother reports that the child is also not really defiant. The symptoms occur at any time of the day and are only momentarily relieved by reprimanding. The mother rates the severity of the symptoms at 8/10 on a scale of 1-10 ADHD SOAP Note example.
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Current medications: The child is not on any medications at the moment.
Allergies: He is allergic to penicillin. Mother reports that he is not allergic to any other medication, foods, or environmental factors.
Past Medical History: He had pneumonia at age 3 which was successfully treated as an in-patient. Given BCG, tetanus/ Diptheria/ Pertussis, and measles vaccines (2012-2013), influenza vaccine (2017), and pneumonia vaccine (2015). The mother reports that he has no history of malaria or meningitis. He also has not suffered any head injury in the past.
Social History: The boy is the second born in a family of four. The elder sibling is a girl aged twelve and she has no medical or mental problems. The father is a computer engineer and the mother is a nurse. The father smokes but drinks only occasionally. The mother neither drinks nor smokes.
Family History: There is no history of mental illness in the family, both from the father’s side and the mother’s side.
Review of Systems (ROS)
Constitutionals: Patient denies feeling hot/ warm. Mother also denies any weight loss in the boy. She however reports excessive hyperactivity, impulsivity, and inattention not accompanied by lack of comprehension. He has no sleep difficulties.
HEENT: The boy reports no dry eyes, itching, or pain. He has no photophobia. He reports no hearing loss, no tinnitus, and is not sneezing. He also has no runny nose and no sore throat.
Respiratory: He has no difficulty in breathing, is not coughing, and has no phlegm.
Cardiovascular: He has no chest discomfort, pain, or palpitations.
Gastrointestinal: Mother reports no vomiting, lack of appetite, or diarrhea.
Genitourinary: The boy denies any burning sensation on urination. No polyuria.
Musculoskeletal: He denies any muscle pain or stiffness.
Neurologic: He denies any headache, instability while walking, numbness, or a change in bladder and/ or bowel control.
Psychiatric: Mother reports that the child has a history of abnormal lack of concentration and hyperactivity. She however denies noting any depressive or anxiety symptoms in him.
Hematologic/ Lymphatic: Both mother and son deny any abnormal bleeding or fatigue. No enlarged nodes.
Endocrine: Mother and son deny excessive urination (polyuria) or excessive water intake (polydipsia). They also deny excessive sweating or heat intolerance.
Allergic/ Immunologic: Mother denies any history of eczema or asthma. Also denies any other seasonal allergies.
OBJECTIVE
Constitutional: The boy is well-groomed and well-nourished. Vital signs: Heart rate: 90; Respiratory rate: 20; Temperature: 98.6°F; Blood pressure: 110/70; Height: 51 inches; Weight: 56 lb; BMI: 15.1 (BMI-for-age at the 33rd percentile). The child has healthy weight (CDC, 2018).
HEENT: Head normocephalic and atraumatic with normal contours. Both pupils equal, round, and reactive to light and accommodation (PERRLA). Intact extraocular muscles. Nasal sinus passages non-tender on palpation. Intact tympanic membrane with no discharge or redness. No halitosis. No exudates in throat.
Neurologic: Cranial nerves are intact with normal symmetric reflexes. Alert and oriented in time, space, person, and place. No motor, sensory, or focal deficit noted.
Psychiatric: Mood congruent with content. Responses hasty but appropriate. Appropriately groomed. Fidgety and restless. Unable to maintain eye contact and concentrate for long.
Diagnostic Laboratory and other Tests: (1) DSM-5 criteria for ADHD. The boy met criteria 1 and 2 for inattention together with hyperactivity and impulsivity (APA, 2013); (2) Blood lead metal levels to rule out lead poisoning which causes similar symptoms (Stahl, 2013); (3) Swanson, Nolan, and Pelham version IV scale teacher form or SNAP-IV to confirm ADHD (Swanson, 2013); (4) Full blood count to rule out any systemic infections (Hammer & McPhee, 2018; Huether & McCance, 2017).
ASSESSMENT
            The differential diagnoses are:

ADHD with combined presentation (314.01[F90.2]). This is the first and most likely diagnosis because the child meets the DSM-5 diagnostic criteria for ADHD (APA, 2013; Stahl, 2013).
Autism spectrum disorder (APA, 2013).
Oppositional defiant disorder (APA, 2013).

PLAN

Behavioral therapy for both the child and the mother, social skills training, cognitive behavioral therapy, and psycho-education (Corey, 2013).
Medication (stimulant). Start methylphenidate (Focalin) 2.5 mg twice a day (Katzung, 2018; Stahl, 2017).
Alternative therapies: (1) A healthy and balanced diet, and (2) Omega-3 vitamin supplements (NHS, 2018).

Health Promotion
The mother should join a support group of parents with children suffering from ADHD in order not to feel as an isolated case. She should also be familiar with the side effects of the Focalin so that she can report them promptly when they occur. Lastly, she should talk to the teachers at school and let them know what her son is suffering from and that he is on medication and therapy (NHS, 2018).
Follow-Up
This will be after four weeks to assess the response to medication and therapy instituted.
Reflection
This experience teaches that ADHD is a condition that can affect the life of a child with lasting implications. It may also be tricky to diagnose because there are other conditions that closely mimic it. Another lesson learnt is that behavioral therapy is an important part of the management of this condition. In this, both the parents and the child should undergo therapy for the best chance of success in remission.     
 
 
 
References
American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Arlington, VA: Author.
Centres for Disease Control and Prevention [CDC] (October 22, 2018). BMI percentile calculator for child and teen. Retrieved 1 April 2020 from https://www.cdc.gov/healthyweight/bmi/calculator.html
Corey, G. (2013). Theory and practice of counseling and psychotherapy, 9th ed. Belmont, CA: Cengage Learning.
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. New York, NY: McGraw-Hill Education.
Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. St. Louis, MO: Elsevier, Inc.
Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. New York, NY: McGraw-Hill Education.
NHS (May 30, 2018). Attention-deficit/ hyperactivity disorder (ADHD). Retrieved 1 April 2020 from https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/treatment/
Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. New York, NY: Cambridge University Press.
Stahl, S.M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical application, 4th ed. New York, NY: Cambridge University Press.
Swanson, J.M. (2013). Swanson, Nolan and Pelham Teacher and Parent Rating Scale (Snap-IV). Retrieved 1 April 2020 from https://www.mcpap.com/pdf/SNAPIV.pdf
 
Assignment 1: Practicum – SOAP Note #2

Select a patient who you examined during the last 3 weeks. ( we can put 8 years old boy with attention deficit hyperactivity disorder). With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.

Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.

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? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
 

Excellent
Good
Fair
Poor

Subjective: CC

(1 point)
1 (1%) – 1 (1%)
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)

Subjective: Pertinent positives LOCATES

(10 points)
9 (9%) – 10 (10%)
Includes thorough, accurate, and pertinent positives LOCATES ADHD SOAP Note example
8 (8%) – 8 (8%)
Includes accurate and pertinent positives LOCATES
7 (7%) – 7 (7%)
Includes positives LOCATES
0 (0%) – 6 (6%)
Does not include positives LOCATES or positives LOCATES are not pertinent

Subjective: Pertinent negatives (from ROS)

(10 points)
9 (9%) – 10 (10%)
Includes thorough, accurate, and pertinent negatives (from ROS)
8 (8%) – 8 (8%)
Includes accurate and pertinent negatives (from ROS)
7 (7%) – 7 (7%)
Includes negatives (from ROS)
0 (0%) – 6 (6%)
Does not include negatives (from ROS) or negatives (from ROS) are not pertinent

Subjective: Pertinent PMH, SH, and FH

(3 points)
0 (0%) – 3 (3%)
Includes thorough, accurate, and pertinent PMH, SH, and FH
0 (0%) – 0 (0%)
NA
2 (2%) – 2 (2%)
Includes PMH, SH, and FH
0 (0%) – 1 (1%)
Does not include PMH, SH, and FH or PMH, SH, and FH are not pertinent

Subjective: Medications and drug/food allergies are not included

(1 point)
1 (1%) – 1 (1%)
Does not include medications and drug/food allergies
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Includes medications and drug/food allergies

Objective: VS including BMI

(2 points)
2 (2%) – 2 (2%)
Includes VS including BMI
0 (0%) – 0 (0%)
NA ADHD SOAP Note example
0 (0%) – 0 (0%)
NA
0 (0%) – 1 (1%)
Does not include VS including BMI

Objective: Heart and lungs

(1 point)
0 (0%) – 1 (1%)
Includes heart and lungs
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include heart and lungs

Objective: Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included.

(5 points)
5 (5%) – 5 (5%)
Includes thorough explanation of systems or specialty exam techniques that are not necessary to arrive at a diagnosis
4 (4%) – 4 (4%)
Includes systems or specialty exam techniques that are not necessary to arrive at a diagnosis
0 (0%) – 0 (0%)
NA
0 (0%) – 3 (3%)
Does not include systems or specialty exam techniques that are not necessary to arrive at a diagnosis

Objective: Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted.

(10 points)
9 (9%) – 10 (10%)
Omits systems or specialty exam techniques that are necessary to arrive at your diagnosis
8 (8%) – 8 (8%)
Omits most systems or specialty exam techniques that are necessary to arrive at your diagnosis
7 (7%) – 7 (7%)
Omits some systems or specialty exam techniques that are necessary to arrive at your diagnosis
0 (0%) – 6 (6%)
Does not omit systems or specialty exam techniques that are necessary to arrive at your diagnosis

Objective: Diagnostic test results

(2 points)
2 (2%) – 2 (2%)
Includes diagnostic test results
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 1 (1%)
Does not include diagnostic test results

Assessment: Priority Diagnosis

(30 points – 10 points for each priority diagnosis. If less than 3 are appropriate to include – simply no other diagnoses to consider – you will receive all 30 points. Please do not “stretch” to find 3 if they are not actual possibilities.)
27 (27%) – 30 (30%)
Includes three appropriate priority diagnoses
24 (24%) – 26 (26%)
Includes three appropriate priority diagnoses but some are incorrect or missing
22 (22%) – 23 (23%)
Includes fewer than three priority diagnoses but some are incorrect or missing
0 (0%) – 21 (21%)
Does not include three appropriate diagnoses

Plan: Medications discontinued (“d/c lisinopril 10 mg daily”)

(1 point)
1 (1%) – 1 (1%)
Includes discontinued medications
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include discontinued medications

Plan: Medications started (“start Avapro 150 mg daily”)

(2 points)
2 (2%) – 2 (2%)
Includes medications started
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 1 (1%)
Does not include medications started

Plan: Alternative therapies if appropriate (1 point)
0 (0%) – 1 (1%)
Includes alternative therapies if appropriate ADHD SOAP Note example
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include alternative therapies if appropriate

Plan: Health Promotion strategies – patient/family education

(3 points)
0 (0%) – 3 (3%)
Includes health promotion strategies – patient/family education
0 (0%) – 0 (0%)
NA
2 (2%) – 2 (2%)
Includes health promotion strategies – patient/family education, but may not be entirely appropriate for the patient/family
0 (0%) – 1 (1%)
Does not include health promotion strategies – patient/family education

Plan: Disease Prevention strategies with timeframe if appropriate

(3 points)
3 (3%) – 3 (3%)
Includes disease prevention strategies with timeframe if appropriate
0 (0%) – 0 (0%)
NA
2 (2%) – 2 (2%)
Includes disease prevention strategies, but does not include timeframe or disease prevention strategies are not appropriate
0 (0%) – 1 (1%)
Does not include disease prevention strategies

Plan: Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months)

(3 points)
3 (3%) – 3 (3%)
Includes appropriate diagnostic tests ordered with timeframe
0 (0%) – 0 (0%)
NA
2 (2%) – 2 (2%)
Includes diagnostic tests but they may not be appropriate, or the timeframe is incorrect or not included
0 (0%) – 1 (1%)
Does not include diagnostic tests

Plan: Referrals or consultations if appropriate

(1 point)
1 (1%) – 1 (1%)
Includes referrals or consultations if appropriate
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include referrals or consultations if appropriate

Plan: Follow-up interval

(1 point)
1 (1%) – 1 (1%)
Includes follow-up interval
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include follow-up interval

Reflection Notes: What did you learn from this experience? Any ah-ha’s?

(10 points)
0 (0%) – 10 (10%)
Response includes thoughtful and insightful explanation of significant learnings
8 (8%) – 8 (8%)
Response includes thoughtful and insightful explanation of learnings ADHD SOAP Note example
7 (7%) – 7 (7%)
Response includes explanation of learnings
0 (0%) – 6 (6%)
Response does not include explanation of learnings

Total Points: 100


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