Description
Complete an interactive simulation that includes interviews of a patient, family members, and experienced health care workers. Then, develop a care coordination strategy and a care plan for the patient based on the information gathered from the interviews.Note: Each assessment in this course builds on your work from the preceding assessment; therefore, complete the assessments in the order in which they are presented.
Whether designing care plans directed by patients’ needs and preferences, educating patients and their families at discharge, or doing their best to facilitate continuity of care for patients across settings and among providers, registered nurses use accredited health care standards to realize coordinated care. This assessment provides an opportunity for you to explore health care standards with respect to the quality of care, investigate opportunities and challenges in care coordination, and develop a proactive, patient-centered care plan.
The National Strategy for Quality Improvement in Health Care (2011) focuses on improving patient care, maximizing health resources, and reducing preventable hospital readmissions. Care coordinators reduce readmissions of those suffering from chronic conditions (such as congestive heart failure, pneumonia, asthma, and diabetes) and are responsible for providing quality care in a fiscally responsible manner. While this may seem a reasonable task, shifting the way we use health care resources can be a challenge. Consequently, you must be cognizant of effective strategies for reducing preventable readmissions and understand the barriers that nurses face when coordinating care for patients with chronic illnesses.
Reference
Agency for Healthcare Research and Quality. (2011). 2011 report to Congress: National strategy for quality improvement in health care. AHRQ. https://www.ahrq.gov/workingforquality/reports/201…Note: Complete the assessments in this course in the order in which they are presented.
As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
To what extent does a needs assessment support nursing diagnoses?
Which standards or benchmarks drive outcomes in your current professional practice?
What action might you take in response to care plan goals or outcomes that are not being met?
To prepare for this assessment, complete the following simulation:
Vila Health: Care Coordination Scenario I.
In this simulation, you will obtain the information needed to develop a care coordination strategy for Mrs. Snyder and her family. You may use an intervention developed as part of your first assessment. Locate applicable current standards and benchmarks as you determine the best way to develop this strategy.
Note: As you revise your writing, check out the resources listed on the Writing Center’s Writing Support page.
Unformatted Attachment Preview
Patient Care Plan
Name:
Date:
Patient Identifier:
Patient Medical Diagnosis:
Nursing Diagnosis
Assessment Data
Include 3–5 pieces of data
(subjective, objective, or a
combination) that led to a nursing
diagnosis.
Goals and Outcome
Nursing Interventions
Rationale
Write two goal statements for each
nursing diagnosis. Goals must be
patient- and family-focused,
measurable, attainable, reasonable,
and time-specific.
List at least three nursing or
collaborative interventions; provide
the rationale for each goal and
outcome.
Explain why each intervention is
indicated or therapeutic; cite
applicable references that support
each intervention.
Outcome Evaluation
and Re-planning
Were the goals met? How would you
revise the plan of care according the
patient’s response to the current plan
of care? Support your conclusions
with outcome measures and
professional standards.
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Document Format: Margins are 1 in. (2.54 cm) on all sides.
All text in the document should be double-spaced.
The font is 12-point Times New Roman. Other choices are 11-point Arial and 11-point Calibri.
The title page is page 1.
There is no running head for learner assignments. (See Academic Writer: Publication Manual §§ 2.1–2.24
for paper requirements.)
Full Title of Your Paper
Learner’s Full Name (no credentials)
School of Nursing and Health Sciences, Capella University
Course Number: Course Name
Instructor’s Name
Month, Year
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Abstract
An abstract is useful in professional papers, but not always in learner assignments. In fact,
unless you are instructed by your faculty or in the course syllabus, do not expect to use
abstracts very often at Capella. If you are submitting for publication, remember to check
with the journal or professional organization about their criteria for an abstract. The
abstract tells your reader about the article, is brief, and stands alone, so no citations are included.
The format for an abstract is a single paragraph (not indented on the first line) that follows the
title page and is less than 250 words in length. A structured abstract will have a single paragraph
without indentation but having labels (e.g., Objective, Method, Results, and Conclusions) on the
same line as the text and bold. For published works, the publishing organization will give you
guidance on these. However, for student papers, no abstract is needed unless the faculty request
one or the assignment requires it. Remember, no citations.
Keywords: include keywords in the abstract—they should be labeled like this, with the
words all in lowercase and separated by commas. Only the first line is indented, like a regular
paragraph. No period at the end.
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APA Style Seventh Edition Paper Template: A Resource for Academic Writing
American Psychological Association (APA) style is one of the most popular methods
used to cite sources in the social sciences, but it is not the only one. When writing papers in the
programs offered at Capella University, you will likely use APA style. This document serves as
an APA style resource for the seventh edition guidelines, containing valuable information that
you can use when writing academic papers. For more information on APA style, refer to the
Publication Manual of the American Psychological Association, also referred to as the APA
manual (American Psychological Association, 2020b).
The first section of this paper shows how an introduction effectively introduces the reader
to the topic of the paper. In APA style, an introduction never gets a heading. For example, this
section did not begin with a heading titled “Introduction,” unlike the following section, which is
titled “Writing an Effective Introduction.” The following section will explain in greater detail a
model that can be used to effectively write an introduction in an academic paper. The remaining
sections of the paper will continue to address APA style and effective writing concepts,
including section headings, organizing information, the conclusion, and the reference list.
Writing an Effective Introduction
An effective introduction often consists of four main components, including (a) the
position statement, thesis, or hypothesis, which describes the author’s main position; (b) the
purpose, which outlines the objective of the paper; (c) the background, which is general
information needed to understand the content of the paper; and (d) the approach, which is the
process or methodology the author uses to achieve the purpose of the paper. This information
will help readers understand what will be discussed in the paper. It can also serve as a tool to
grab the reader’s attention. Authors may choose to briefly reference sources that will be
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identified later in the paper as in this example (American Psychological Association, 2020a;
American Psychological Association, 2020b). The Writing Center has developed the acronym
POETS to help describe the proper writing style for submissions. POETS is the acronym for
purpose, organization, evidence, tone, and sentence structure (Capella Writing Center, n.d.).
There will be more on this later.
In an introduction, the writer will often present something of interest to capture the
reader’s attention and introduce the issue. Adding an obvious statement of purpose helps the
reader know what to expect, while helping the writer to focus and stay on task. For example, this
paper will address several components necessary to effectively write an academic paper,
including how to write an introduction, how to write effective paragraphs, and how to effectively
use APA style.
Level 1 Section Heading Is Centered, Bold, and Title Case
Using section headings can be an effective method of organizing an academic paper.
Section headings are not required according to APA style; however, they can significantly
improve the quality of a paper by helping both the reader and the author, as will soon be
discussed.
Level 2 Section Heading Is Aligned Left, Bold, and Title Case
The heading style recommended by APA consists of five levels (APA, 2020b, pp. 47–
48). This document contains multiple levels to demonstrate how headings are structured
according to APA style. Immediately before the previous paragraph, a Level 1 section heading
was used. That section heading describes how a Level 1 heading should be written, which is
centered, bold, and using uppercase and lowercase letters (also referred to as title case). For
another example, see the section heading “Writing an Effective Introduction” on page 3 of this
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document. The heading is centered and bold and uses uppercase and lowercase letters. If used
properly, section headings can significantly contribute to the quality of a paper by helping the
reader, who wants to understand the information in the document, and the author, who desires to
effectively describe it.
Section Heading Purposes
Section Headings Help the Reader. Section headings serve multiple purposes, including
helping the reader understand what is being addressed in each section, maintain an interest in the
paper, and choose what they want to read. For example, if the reader of this document wants to
learn more about writing an effective introduction, the previous section heading clearly states
that is where information can be found. When subtopics are needed to explain concepts in greater
detail, different levels of headings are used according to APA style.
Section Headings Help the Author. Section headings not only help the reader; they also
help the author organize the document during the writing process. Section headings can be used
to arrange topics in a logical order, and they can help an author manage the length of the paper.
In addition to an effective introduction and the use of section headings, each paragraph of an
academic paper can be written in a manner that helps the reader stay engaged.
Section Headings Can Demonstrate Fine Detail. Short papers and assignments may not
require or need a Level 5 heading, but these will be indented, bold, italic, and title case and end
with a period. Note the text starts on the line at the end of the heading following the period.
How to Write Effective Paragraphs
Capella University’s Writing Center (n.d.) has adopted a new set of writing standards to
assist learners in their goals to improve their scholarly writing. It is based on five skills known by
the mnemonic POETS. In other words, a well-developed Capella paper will demonstrate the
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following standards. The paper will have a clear purpose statement, be logically organized,
utilize current and appropriate evidence that is properly cited, maintain a scholarly tone, and
demonstrate proper grammar and writing mechanics in the sentence structure (Capella Writing
Center, n.d.). Academic writing is sometimes considered dry and boring. A learning experience
may need that formula to encourage learning in different ways as the learner moves from passive
learner to active scholar. This growth, according to Gilmore et al. (2019), requires the writer to
not only think but also to write differently.
Bias-Free Language
In the seventh edition of the APA manual, another focus is on eliminating bias in
language in order to provide a more inclusive tone in scholarly writing. While long considered a
grammar issue, it is acceptable in APA to utilize they as a singular pronoun (APA, 2020b). In
fact, there is an entire chapter of the manual dedicated to ways to reduce bias in scholarly
writing. It is important to use an appropriate level of specificity in descriptions and use
sensitivity with the use of labels. Other sections include guidelines on age, disability, gender,
race and ethnicity, sexual orientation, socioeconomic status, and participation in research. Be
aware of intersectionality, a term used to describe a person based on their identified multiple
identities, interconnectivity, social context, power relations, complexity, social justice, and
inequalities that can result in oppression (Cole, 2019; Hopkins, 2017).
Considering Direct Quotations
Another important point to consider is the use of direct quotations in papers. While
plagiarism is considered an academic integrity issue, many learners are concerned with issues
such as self-plagiarism and unintentional plagiarism, and there are others who may go as far as
purchasing papers for submission (Colella & Alahmadi, 2019). As a learner travels along their
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chosen academic pathway, their writing skills and mechanics are expected to improve. It is
imperative that the learner transition from finding information and quoting the author word for
word to using the information to support an idea, paraphrase, and then synthesize and express the
findings in one’s own words. Having said that, there are situations in which quotations may be
appropriate, so it is important to cite them properly. According to the seventh edition of the APA
manual, “When quoting directly, always provide the author, year, and page number of the
quotation in the in-text citation in either parenthetical or narrative format” (APA, 2020b, p. 270).
If there are not page numbers, identify the location in another manner (such as a paragraph
number).
Notice that the above quote contains fewer than 40 words. There is a different style for
quotes containing 40 words or more. These longer quotes use a block quotation format:
Do not use quotation marks to enclose a block quotation. Start a block quotation on a new
line and indent the whole block 0.5 in. from the left margin. If there are additional
paragraphs within the quotation, indent the first line of each subsequent paragraph an
additional 0.5 in. Double-space the entire block quotation; do not add extra space before
or after it. Either (a) cite the source in parentheses after the quotation’s final punctuation
or (b) cite the author and year in the narrative before the quotation and place only the
page number in parentheses after the quotation’s final punctuation. Do not add a period
after the closing parenthesis in either case. (APA, 2020b, p. 272)
Conclusion
A summary and conclusion section, which can also be the discussion section of an APA
style paper, is the final opportunity for the author to make a lasting impression on the reader. The
author can begin by restating opinions or positions and summarizing the most important points
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that have been presented in the paper. For example, this paper was written to demonstrate to
readers how to effectively use APA style when writing academic papers. Various components of
an APA style paper that were discussed or displayed in the form of examples include a title page,
introduction section, levels of section headings and their use, the POETS format, bias-free
language, in-text citations, a conclusion, and the reference list.
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References
American Psychological Association. (2020a). Ethical principles of psychologists and code of
conduct (2002, amended effective June 1, 2010, and January 1, 2017).
https://doi.org.apa.org/ethics/code/index.aspx
American Psychological Association. (2020b). Publication manual of the American
Psychological Association (7th ed.).
Capella University. (n.d.). Writing Center. https://campus.capella.edu/writing-center/home
Cole, N. L. (2019, October 13). Definition of intersectionality: On the intersecting nature of
privileges and oppression. ThoughtCo. https://www.thoughtco.com/intersectionalitydefinition-3026353
Colella, J., & Alahmadi, H. (2019). Combating plagiarism from a transformation viewpoint.
Journal of Transformative Learning, 6(1), 59–67.
https://jotl.uco.edu/index.php/jotl/article/view/184
Gilmore, S., Harding, N., Helin, J., & Pullen, A. (2019). Writing differently. Management
Learning, 50(1), 3–10. https://doi.org/10.1177/1350507618811027
Hopkins, P. (2017). Social geography I: Intersectionality. Progress in Human Geography, 43(5),
937–947. https://doi.org/10.1177/0309132517743677
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Appendix
Tips for the Reference List
•
Always begin a reference list on a new page. It should be placed before any appendices, figures,
or tables and titled References.
•
Set a hanging indent that starts with the second line and is double-spaced. You can look in the
Paragraph menu of Microsoft Word for formatting the hanging indent so that you will not have to
tab the indent. It gives the text a smoother look that remains consistent, even if you make edits.
•
The reference list is in alphabetical order by the first author’s last name. A reference list only
contains sources that are cited in the body of the paper, and all sources cited in the body of the
paper must be included in the reference list. If you did not cite it, do not list it.
•
The reference list above contains an example of how to cite a source when two documents are
written in the same year by the same author.
•
•
o
The lowercase letters are used after the date to differentiate the sources. The “a” reflects
the alphabetical order in the reference list—not whether it appeared first in the text.
o
The year is also displayed using this method for the corresponding in-text citations, as in
the following sentence: The author of the first citation (American Psychological
Association, 2020b) is also the publisher; therefore, the word Author is no longer used in
the seventh edition.
DOI is the digital object identifier.
o
It can be found on the first page of an article, on the copyright page of a book, in the
database record of a work, or by searching Crossref.
o
Even if the book is in print, if there is a DOI, use it.
o
Always use the hyperlink format for a DOI—it will always start with https://doi.org/ and will
be followed by a number. If the DOI is not in this format, convert it. Do not alter this
format, and do not add a final period.
o
There is a short DOI service at http://shortdoi.org/.
URL is the uniform resource locator.
o
If there is no DOI, the URL should be used in the reference.
o
Copy and paste the URL directly into your list.
o
Do not add a period at the end.
o
Do use “Retrieved from” before a URL.
•
The Colella and Alahmadi reference is an example of how to cite a source using a URL. Please
note that you will not use the Capella link that is often provided in the courseroom. If the URL
contains a database title, such as EBSCO or ProQuest, or the name Capella, do not use that in
your citation as it will only work for Capella learners and faculty.
•
For examples and further information on references go to:
o
Academic Writer: Sample References.
o
Academic Writer: Reference List.
12/17/23, 9:22 PM
Evidence-Based Patient-Centered Needs Assessment Scoring Guide
Evidence-Based Patient-Centered Needs Assessment Scoring Guide
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
Identify the
importance of
addressing patient
engagement in the
management of a
patient’s specific
health, economic,
and cultural needs
based on the best
available evidence.
Does not identify
reasons for why
patient
engagement is
important
Identifies reasons
for why patient
engagement is
important, but does
not do so within the
context of one or
more of a patient’s
specific health,
economic, and
cultural needs
based on the best
available evidence.
Identifies the
importance of
addressing patient
engagement in the
management of a
patient’s specific
health, economic,
and cultural needs
based on the best
available evidence.
Identifies the importance of
addressing patient
engagement in the
management of a patient’s
specific health, economic,
and cultural needs based on
the best available evidence.
Provides specific examples
of patient engagement
strategies that would be
appropriate to apply to the
chosen patient.
Explain the potential
use and impact of
information and
communication
technology tools
needed to improve
consumer health
literacy for a specific
patient population.
Does not identify
the potential use
and impact of
information and
communication
technology tools
needed to improve
consumer health
literacy for a
specific patient
population.
Identifies the
potential use and
impact of
information and
communication
technology tools
needed to improve
consumer health
literacy for a specific
patient population.
Explains the
potential use and
impact of
information and
communication
technology tools
needed to improve
consumer health
literacy for a
specific patient
population.
Explains the potential use
and impact of information
and communication
technology tools needed to
improve consumer health
literacy for a specific patient
population. Supports
explanation with specific
reference to evidence from
professional best-practice or
scholarly sources. Identifies
unanswered questions or
areas of uncertainty about
the individual needs of the
patient or their family, where
further information could
improve the analysis.
Evaluate the value
and relevance of the
technology
modalities that may
be used to address
the needs identified
in the patient
population
assessment.
Does not explain
technology
modalities that may
be used to
modalities that may
be used to address
the needs identified
in the patient
population
assessment.
Does not explain
technology
modalities that may
be used to
modalities that may
be used to address
the needs identified
in the patient
population
assessment.
Evaluates the value
and relevance of
the technology
modalities that may
be used to address
the needs identified
in the patient
population
assessment.
Evaluates the value and
relevance of the technology
modalities that may be used
to address the needs
identified in the patient
population assessment.
Notes how exchange and
interoperability of technology
modalities contribute to their
value. Notes specific ways in
which the communication
strategies promote honest
communication, facilitate
sharing only information that
is permitted under data
privacy rules, and help to
make complex medical
terms and concepts
understandable to your
patient and their family,
regardless of language,
abilities, or educational level.
Identify innovative
strategies for
leveraging
technology to
Does not identify
strategies for
leveraging
technology to
Identifies strategies
for leveraging
technology to
support patient care.
Identifies innovative
strategies for
leveraging
technology to
Identifies innovative
strategies for leveraging
technology to support
quality, ethical, and efficient
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Evidence-Based Patient-Centered Needs Assessment Scoring Guide
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
support quality,
ethical, and efficient
patient care that is
culturally and
linguistically
appropriate for the
identified patient
population.
support patient
care.
However, does not
fully address how
that technology
relates to quality,
ethical, and efficient
patient care that is
culturally or
linguistically
appropriate for the
patient population.
support quality,
ethical, and efficient
patient care that is
culturally and
linguistically
appropriate for the
identified patient
population.
patient care that is culturally
and linguistically appropriate
for the identified patient
population. Make reference
to evidence from
professional best-practices
or scholarly sources to
support the use of the
identified strategies.
Explain how the
proposed strategies
will mitigate the risk
of adverse
outcomes due to
inequity in access to
patient personal
health data and
technology
modalities.
Does not describe
how the proposed
strategies may
mitigate the risk of
adverse outcomes.
Describes how the
proposed strategies
may mitigate the
risk of adverse
outcomes, but the
connection to
inequity in access to
patient personal
health data or
technology
modalities is either
unclear or missing.
Explains how the
proposed strategies
will mitigate the risk
of adverse
outcomes due to
inequity in access to
patient personal
health data and
technology
modalities.
Explains how the proposed
strategies will mitigate the
risk of adverse outcomes
due to inequity in access to
patient personal health data
and technology modalities.
Supports the explanation
with specific examples of
strategies that have
previously been applied to
mitigate risks and address
iniquities.
Convey purpose of
the assessment
narrative in an
appropriate tone and
style, incorporating
supporting
evidence, and
adhering to
organizational,
professional, and
scholarly
communication
standards.
Does not convey
purpose of the
assessment
narrative, in an
appropriate tone
and style,
incorporating
supporting
evidence and
adhering to
organizational,
professional, and
communication
scholarly
standards.
Conveys purpose of
the assessment
narrative, in an
appropriate tone or
style. Clear,
effective
communication is
inhibited by
insufficient
supporting evidence
and minimal
adherence to
applicable
communication
standards.
Convey purpose of
the assessment
narrative in an
appropriate tone
and style,
incorporating
supporting evidence
and adhering to
organizational,
professional, and
scholarly
communication
standards. Uses
APA style and
formatting.
Conveys clear purpose of
the assessment narrative, in
a tone and style well-suited
to the intended audience.
Supports assertions,
arguments, and conclusions
with relevant, credible, and
convincing evidence.
Exhibits strict and nearly
flawless adherence to
organizational, professional,
and scholarly
communication standards,
including APA style and
formatting.
Integrate relevant
and credible
sources of evidence
to support
assertions, correctly
formatting citations
and references
using APA style.
Does not integrate
credible sources of
evidence or apply
APA formatting to
in- text citations
and references.
Integrates credible
sources of
evidence, but the
sources used is not
relevant or do not
well- support
assertions. APA
formatting of in-text
citations and
references is
incorrect or
inconsistent,
detracting
noticeably from
good scholarship.
Integrates relevant
and credible
sources of evidence
to support
assertions, correctly
formatting citations
and references
using APA style.
Integrates relevant and
credible sources of evidence
to support assertions.
Exhibits strict and nearly
flawless adherence to APA
style of in-text citations and
references.
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