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PRAC 6531 Week 3 Assgn 2
EPISODIC VISIT: HEENT FOCUSED NOTE
Focused Notes are a way to reflect on your practicum experiences and connect the
experiences to the learning you gain from your weekly learning resources. Focused Notes,
such as the ones required in this practicum course, are often used in clinical settings to
document patient care.
For this Assignment, you will work with a patient with a HEENT condition that you
examined during the last three weeks, and complete an Episodic/Focus Note Template
Form where you will gather patient information and relevant diagnostic and treatment
information and reflect on health promotion and disease prevention in light of patient
factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and
cultural background. In this week’s Learning Resources, please refer to the Focused SOAP
Note resources for guidance on writing Focused Notes.
Note: All Focused Notes must be signed, and each page must be initialed by your
preceptor. When you submit your Focused Notes, you should include the complete
Focused Note as a Word document and pdf/images of each page that is initialed and
signed by your preceptor. You must submit your Focused Notes using Turnitin.
Note: Electronic signatures are not accepted. If both files are not received by the due
date, faculty will deduct points per the Walden Late Policies.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
To prepare:
•
•
Use the Episodic/Focus Note Template found in the Learning Resources for this
week to complete this assignment.
Select a patient that you examined during the last three weeks that suffered
from any HEENT condition. With this patient in mind, address the following in a
Focused Note:
Assignment:
•
•
•
•
•
Subjective: What details did the patient provide regarding her personal and
medical history?
Objective: What observations did you make during the physical assessment?
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, including alternative therapies?
Include pharmacologic and nonpharmacologic treatments, alternative
therapies, and follow-up parameters, as well as a rationale for this treatment
and management plan.
Reflection notes: What would you do differently in a similar patient evaluation?
Note: Your Focused Note Assignment must be signed by Day 7 of Week 3.
BY DAY 7
Submit your Episodic/Focused Note Assignment.
(Note: You will submit two files, your Focused Note Assignment, and a Word document of
pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week
3.)
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To
check your draft, access the Turnitin Drafts from the Start Here area.
1. To submit your completed assignment, save your Assignment
as WK3Assgn2_LastName_Firstinitial
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.
Rubric
PRAC_6531_Week3_Assignment2_Rubric
PRAC_6531_Week3_Assignment2_Rubric
Criteria
Ratings
Pts
This criterion is linked
to a Learning
OutcomeOrganization
of Write-up
10 to >6.0 pts
Excellent
All information
organized in
logical sequence;
follows
acceptable format
and utilizes
expected
headings.
This criterion is linked
to a Learning
OutcomeThoroughness
of History
6 to >3.0 pts
Good
Information
generally
organized in
logical sequence;
follows acceptable
format and utilizes
expected headings.
20 to >15.0 pts
Excellent
Thoroughly documents
all pertinent history
components for type of
note; includes critical
as well as supportive
information.
15 to >11.0 pts
Good
Documents
most pertinent
examination
components.
3 to >0.0 pts
Fair
Errors in format;
information
intermittently
organized.
Headings are used
some of the time.
0 pts
Poor
Errors in format;
information
disorganized.
Headings are not
used
appropriately.
11 to >7.0 pts
Fair
Documents
some pertinent
examination
components.
7 to >0 pts
Poor
Physical
examination
cursory; misses
several pertinent
components.
10 pts
20 pts
PRAC_6531_Week3_Assignment2_Rubric
Criteria
This criterion is linked
to a Learning
OutcomeHistory of
Present Illness
This criterion is linked
to a Learning
OutcomeThoroughness
of Physical Exam
Ratings
10 to >6.0 pts
Excellent
Thoroughly
documents all 8
aspects of HPI and
pertinent other data
relevant to chief
complaint. Includes
critical as well as
supportive
information.
6 to >4.0 pts
Good
Documents at least
6 aspects of the
HPI and pertinent
other data relevant
to chief complaint.
Includes critical
information.
10 to >7.0 pts
Excellent
Thoroughly
documents all
pertinent
examination
components for type
of note.
7 to >4.0 pts
Good
Documents most
pertinent
examination
components.
4 to >2.0 pts
Fair
Documents at least
4 aspects of HPI
and some data
pertinent to chief
complaint. Lacks
some critical
information or
rambling in
history.
4 to >2.0 pts
Fair
Documents some
pertinent
examination
components.
Pts
2 to >0 pts
Poor
Missing many
aspects of HPI
and pertinent
data. Critical
information
missing.
2 to >0 pts
Poor
Physical
examination
cursory; misses
several pertinent
components.
10 pts
10 pts
PRAC_6531_Week3_Assignment2_Rubric
Criteria
This criterion is linked
to a Learning
OutcomeDiagnostic
Reasoning
Ratings
Pts
10 to >7.0 pts
Excellent
Assessment
consistent with
prior
documentation.
Clear justification
for diagnosis.
Notes all
secondary
problems. Cost
effective when
ordering
diagnostic tests.
7 to >4.0 pts
Good
Assessment
consistent with
prior
documentation.
Clear justification
for diagnosis.
Notes most
secondary
problems.
4 to >2.0 pts
Fair
Assessment
mostly consistent
with prior
documentation.
Fails to clearly
justify diagnosis or
note secondary
problems or orders
inappropriate
diagnostic tests.
2 to >0 pts
Poor
Assessment not
consistent with
prior
documentation.
Fails to clearly
justify diagnosis
or note secondary
problems or orders
inappropriate
diagnostic tests.
20 to >15.0 pts
Excellent
Treatment plan
addresses all issues
raised by diagnoses,
excellent insight into
patient’s needs.
Medications
prescribed are
appropriate and full
prescription is
included. Evidence
based decisions.
Cost effective
treatment.
15 to >10.0 pts
Good
Treatment plan
addresses most
issues raised by
diagnoses.
Medications
prescribed are
appropriate but
include 1 or 2
error in writing
prescription.
10 to >5.0 pts
Fair
Treatment plan
fails to address
most issues raised
by diagnoses.
Medications are
inappropriate or
include 3 or more
errors in writing
prescription.
5 to >0 pts
Poor
Minimal
treatment plan
addressed.
Medications are
inappropriate or
poorly written
prescription.
10 pts
This criterion is linked
to a Learning
OutcomeTreatment
Plan/Patient Education
20 pts
PRAC_6531_Week3_Assignment2_Rubric
Criteria
This criterion is linked
to a Learning
OutcomePatient
Education / Follow Up
/ Reflection
This criterion is linked
to a Learning
OutcomeWritten
Expression and
Formatting English
writing standards:
Correct grammar,
mechanics, and proper
punctuation.
Professional language
utilized
Ratings
10 to >8.0 pts
Excellent
Patient education
addresses all
issues raised by
diagnoses,
excellent insight
into patient’s
needs. Follow up
plan in appropriate
and reflects acuity
of illness.
Reflection is
thoughtful and in
depth.
5 pts
Excellent
Uses correct
grammar,
spelling, and
punctuation
with no errors.
Professional
language
utilized.
8 to >5.0 pts
Good
Patient
education
addresses most
issues raised by
diagnoses.
Follow up plan
is appropriate
but lacks
specifics
Reflection is
thoughtful and
in depth.
4 pts
Good
Contains a few
(1-2) grammar,
spelling, and
punctuation
errors. Contains a
few errors (1 or
2) in professional
language use.
Pts
5 to >3.0 pts
Fair
Patient education fails
to address most issues
raised by diagnoses.
Follow up plan is
lacking specifics or is
inappropriate for
patient acuity.
Reflection is brief,
vague. and does not
discuss anything that
would have been done
in addition to or
differently.
2 pts
Fair
Contains several
(3-4) grammar,
spelling, and
punctuation
errors. Contains
several errors (3 4) in professional
language use.
3 to >0 pts
Poor
Minimal patient
education
addressed.
Follow up plan
is inappropriate
Reflection is
absent.
0 pts
Poor
Contains many (≥ 5)
grammar, spelling,
and punctuation errors
that interfere with the
reader’s
understanding.
Contains many errors
in professional
language use.
10 pts
5 pts
PRAC_6531_Week3_Assignment2_Rubric
Criteria
This criterion is linked
to a Learning
OutcomeScholarly
References and
Clinical Practice
Guidelines. The
assignment includes a
minimum of 3
scholarly references
that are not older than
5 years. Clinical
practice guidelines are
included if applicable.
Total Points: 100
PreviousNext
Ratings
5 pts
Excellent
Contains
parenthetical/intext citations and
at least 3
evidenced based
references less
than 5 years old
are listed. Clinical
practice guidelines
are cited if
applicable.
4 pts
Good
Contains
parenthetical/intext citations and
at least 2
evidenced based
references less
than 5 years old
are listed. Clinical
practice guidelines
are cited if
applicable.
2 pts
Fair
Contains
parenthetical/intext citations and
at least 1
evidenced based
reference less than
5 years old is
listed. Clinical
practice guidelines
are not cited if
applicable.
Pts
0 pts
Poor
Contains no
parenthetical/intext citations and
0 evidenced based
references listed.
Clinical practice
guidelines are not
cited if applicable.
5 pts
LEARNING RESOURCES
Required Readings
•
Fowler, G. C. (2020). Pfenninger and Fowler’s procedures for primary care (4th ed.).
Elsevier.
o Section 4: Eyes, Ears, Nose, and Throat
▪ Chapter 62, “Cerumen Impaction Removal” (pp. 388–392)
o Section 13: Urgent Care
▪ Chapter 200, “Corneal Abrasions and Removal of Corneal
or Conjunctival Foreign Bodies” (pp. 1338–1344)
▪ Chapter 201, “Slit-Lamp Examination” (pp. 1345–1349)
▪ Chapter 202, “Auricular Hematoma Evacuation” (pp.
1350–1354)
▪ Chapter 204, “Removal of Foreign Bodies from the Ear
and Nose” (pp. 1359–1364)
▪ Chapter 205, “Management of Epistaxis (pp. 1365–1371)
Practicum Resources
•
•
•
•
•
HSoft Corporation. (2019). Meditrek: Home.Links to an external
site. https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and
patient encounters.
Walden University Field Experience. (2019a). Field experience: College of
NursingLinks to an external
site.. https://academicguides.waldenu.edu/fieldexperience/son/home
Walden University Field Experience. (2019b). Student practicum resources: NP
student orientation.Links to an external
site. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrie
ntation
Walden University. (2019). MSN nurse practitioner practicum manual.Links to an
external
site. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocu
ments
Document: Episodic/Focus Note Template (Word document)Download
Episodic/Focus Note Template (Word document)
Required Media
•
SOAP Notes
In this media program, Dr. Nancy Hadley discusses the expectations for
developing a SOAP note. (27m)
Master of Science in Nursing
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
Episodic/Focus Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here in the
patient’s own words (e.g., “headache,” NOT “bad headache for 3 days”).
HPI: This is the symptom analysis section of your note. Thorough documentation in this
section is essential for patient care, coding, and billing analysis. Paint a picture of what
is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to
start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must
include the seven attributes of each principal symptom in paragraph form not a list. If
the CC was “headache,” the LOCATES for the HPI might look like the following
example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but
not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for
use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a
description of what the allergy is (e.g., angioedema, anaphylaxis). This will help
determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major
illnesses and surgeries. Depending on the CC, more info is sometimes needed
© 2020 Walden University
1
Master of Science in Nursing
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use
(i.e., previous and current use), any other pertinent data. Always add some health
promo question here (e.g., whether they use seat belts all the time or whether they have
working smoke detectors in the house, living environment, text/cell phone use while
driving, and support system).
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses.
Reason for death of any deceased first degree relatives should be included. Include
parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential
diagnosis You should list each system as follows: General: Head: EENT: etc. You
should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations
or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain
or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period,
MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
© 2020 Walden University
2
Master of Science in Nursing
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing
your physical exam. You only need to examine the systems that are pertinent to the CC,
HPI, and History. Do not use “WNL” or “normal.” You must describe what you see.
Always document in head to toe format (i.e., General: Head: EENT: etc.).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to
develop the differential diagnoses (support with evidenced and guidelines).
A.
Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or
presumptive diagnosis should be at the top of the list. For each diagnosis, provide
supportive documentation with evidence based guidelines.
P.
Includes documentation of diagnostic studies that will be obtained, referrals to other
health care providers, therapeutic interventions, education, disposition of the patient and
any planned follow up visits. Each diagnosis or condition documented in the
assessment should be addressed in the plan. The details of the plan should follow an
orderly manner. Also included in this section is the reflection. The student should
reflect on this case and discuss whether or not they agree with their preceptor’s
treatment of the patient and why or why not. What did they learn from this case? What
would they do differently?
Also include in your reflection, a discussion related to health promotion and disease
prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and
other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based peer-reviewed journal articles
or evidenced based guidelines which relates to this case to support your diagnostics
and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
© 2020 Walden University
3
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