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NR511 Course Overview, eLogs and SOAP notes

NR511 Course Overview, eLogs and SOAP notes. Introduction to NR511. Course Resources. The Course Resources tab in the left margin contains many resources to assist you in your clinical courses. Review to find the sample and reference documents documents for the course.

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NR511 Course Overview, eLogs and SOAP notes

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  1. NR511 Course Overview, eLogs and SOAP notes

  2. Introduction to NR511

  3. Course Resources • The Course Resources tab in the left margin contains many resources to assist you in your clinical courses. • Review to find the sample and reference documents documents for the course. • Use preview week to review all these resources

  4. eLogs eLogs is the clinical documentation tool that you use to document all clinical encounters. You create your own clinical log through your entries of all patient encounters. You must document all patients you see. All activities associated with your patient and included in the clinical time for that patient visit, not as alternative encounters. Review the course announcements for the acceptable clinical encounters categories. You are required to document your clinical encounters and include one clinical patient SOAP note in eLogs each week. There are resources in the course to assist you with eLogs. Review the documents and recorded presentation which will explain how to correctly document your time. Contact your instructor with any questions.

  5. NR511 Case Studies This course uses case studies to teach about many of the common problems seen in primary care practice. Not only are you learning about the diagnoses presented but you are also learning how to be a provider. Through your part 1 posting you will learn how to: • Interview a patient thoroughly using OLDCARTS and the ROS as your guide • Develop differential diagnoses using scholarly sources • Choose a focused physical exam and initial diagnostic tests to confirm a diagnosis.

  6. NR511 Case Studies Not only are you learning about the diagnoses presented but you are also learning how to be a provider. Through your part 2 posting you will learn how to: • Prescribe medications and write prescriptions. • Determine a diagnosis and be able to support your diagnosis with scholarly sources using the patient complaint, physical exam and lab results. • Write a complete and accurate SOAP note using the provided case study information.

  7. Rx Writing Review the PowerPoint in Course Resources regarding prescription writing. You will find examples and answers for how to write common prescriptions including how to calculate liquid prescriptions for children. It is a course expectation that all mediations in the case studies, including OTC medications are written in prescription format.

  8. Sample Case Study Part One

  9. Sample Case Study Part 1: Due Tuesday @11:59 p.m. MT Setting: a busy afternoon at a small town retail clinic. You are the only FNP working at a retail clinic. It has been a very busy day full of the usual coughs, colds and other minor complaints common to a retail clinic. The computer tells you that your next patient to see is Julia, a 16 year old girl. You call Julia into the office, her mother is present with her for this visit. Julia looks really tired and unkempt. She is wearing a T shirt and pajama bottoms with flip flops. She has a blanket wrapped around her shoulders. Without answering your greeting, Julia shuffles over to the exam table, climbs up and immediately lies down, wrapped in her blanket. You introduce yourself as you always do and ask Julia what the reason is for the visit today. Julia has her eyes closed and does not respond. Her mother states yesterday Julia started to have cold symptoms. She had a runny nose, watery eyes, cough and a headache. She was really tired so she went to bed early. She did not go to school today, Mom thought a day of rest would help. Mom says when she got home from work this afternoon Julia said she felt even worse so she brought her over to get checked out. Now Julia’s throat really hurts and she is very tired but it’s hard to rest because her legs ache and she feels so cold, she can’t get warm. Julia does feel warm but they did not take the time to check her temperature. Julia is up to date on her vaccinations, she does not have allergies and takes no medications. She did take some Tylenol and Motrin for the headache, it really did not help, in fact she has felt nauseous since she took the last dose of Motrin three hours ago. FH: Julia has an older and younger sibling in good health. SH: Julia is a junior in high school, she gets good grades. She works part time at the mall in the food court. A lot of the kids she works with have been sick, she is not sure what was wrong with them. • What further questions do you have for Julia at this visit??  Why? • What is your differential diagnosis list for this visit thus far with rationale? • Based on your differential diagnoses list, what exams will you perform at this visit? • Are there any lab tests you would like to order? Please include your rationale for the lab, linking the lab to one of your chosen differential diagnoses.

  10. Sample Case Study Part One Questions • Further questions and Why? Follow OLDCARTS first then you can ask additional questions r/t your specific differentials. • O: Onset: One day ago. Did the symptoms come on suddenly? • L: Location: HEENT, legs. Do you fell achy all over your body? • D: Duration: Are you symptoms continuous or intermittent? Have you ever had symptoms like this before? • C: Characteristics/Associated Symptoms: a runny nose, watery eyes, cough, headache, tired, “can not get warm”, nausea, “feels warm”. • A: Aggravating: Does anything make your symptoms worse? • R: Relieving Factors: Does anything make your symptoms better? • T: Treatments: Motrin and Tylenol for ha without relief and caused nausea. Have you used any other OTC or prescription medications for your symptoms? • S: Severity: unable to go to school today. Pain 3/10 for her muscle aches

  11. Case Study Part One: Question 2 • Develop 3 differentials based on an EBP resource for primary care providers or your textbook. • Give a one sentence definition of the pathophysiology (cite your reference) • The common S & S (cite your reference) • Document this patient’s current S & S for each differential, this is how you link the differential to your patient.

  12. 3 Differential Diagnosis • 1. Influenza (ICD9 : 487.1)- a viral respiratory illness affecting the upper respiratory tract and lungs (Reference). S & S: Sudden onset of fever, ha, body aches, fatigue, cough sore throat, & nasal discharge(Hart, 2015). • 2. Acute nasopharyngitis ( ICD 9: 460): The common cold, or upper respiratory tract infection, usually is caused by one of several respiratory viruses, most commonly rhinovirus (Reference). These viruses, which concentrate in nasal secretions, are easily transmitted through sneezing, coughing, or nose blowing. S & S: of the common cold include fever, cough, rhinorrhea, nasal congestion, sore throat, headache, and myalgia(Dunphy et al, 2015). • 3. Infectious Mononucleosis (ICD (: 075): Epstein-Barr virus (EBV) infections are often asymptomatic, some patients present with the clinical syndrome of infectious mononucleosis (IM) (Reference). The syndrome most commonly occurs between 15 and 24 years of age. It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petecchiae (Dunphy et al, 2015)

  13. Case Study Part One: Question 3 • Determine which systems need to be assessed for the ROS and for the focused PE Some students have difficulty differentiating between the ROS and the exam. The ROS is what the patient tells you and is part of the subjective section. The focused PE is the exam results and part of the objective section.

  14. ROS: include only the information given in the case study • General constitutional systems : chills (+), fatigability (+), Are you having night sweats? • Eyes: are you experiencing Change in vision , blurring, acuity, diplopia, photophobia, pain, redness, discharge, loss of vision? • Ears, nose, mouth, sinuses: discharge(+), sore throat (+), Are you having any hoarseness,changein taste, Allergy symptoms, congestion, pain , change in hearing, tinnitus, or sense of smell? • Chest/lungs: cough (+), are you experiencing Dyspnea, cyanosis , wheezing , sputum , hemoptysis, chest pain related to breathing, exposure to TB? • Cardiovascular : any chest pain, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, claudication? • Musculoskeletal : leg pain (+).Any joint pain, stiffness, restriction of motion, redness, warmth, deformity? • Lymph nodes: any \Swelling, tenderness, drainage

  15. FOCUSED PE For Julia you would want to assess HEENT, cardiac, respiratory, abdominal, lymphatic systems Include the detailed exam for each body system you have listed. List which body system you want to examine and include a brief statement of any specialized testing you would want to pay special attention to based on the diagnosis.

  16. Case Study Part One: Question 3 continued Determine which labs and tests you will order to aid in the diagnosing her primary diagnosis. Many sources will include testing for a confirmed diagnosis. Focus on the testing that confirms the diagnosis.

  17. Labs and Tests to be Ordered and Why • Influenza: Rapid Influenza Diagnostic Testing (RIDT). Identifies the presence of influenza A and B viruses in nasopharyngeal specimens (Hart, 2015). • Acute nasopharyngitis : none (Dunphy et al, 2011) • Mono: Heterophile antibody test. This quick screening test detects a type of antibody (heterophil antibody) that forms during certain infections. A sample of blood is placed on a microscope slide and mixed with other substances. If heterophil antibodies are present, the blood clumps (agglutinates). This result usually indicates a mono infection. Monospot testing can usually detect antibodies 2 to 9 weeks after a person is infected. (Reference)

  18. Post 2 HPI and assessment section : the A&P need an EBP reference • S: Subjective • Chief Complaint (CC): cold symptoms x 2 days, worsening. • History of present illness (HPI): O: I started to have cold symptoms yesterday, L & D: no information provided. C: included runny nose, watery eyes, cough and a headache. Was very tired last night and went to bed early. Julia felt even worse this afternoon: throat really hurts, very tired, legs ache feels cold, and can’t get warm. Julia did not go to school today and did not check her temperature. A: no information provided. R & T: Took Tylenol and Motrin for the headache, did not help, and has felt nauseous since she took the last dose of Motrin three hours ago. S: no information provided. • ****Include all other subjective sections and the objective section as noted in the Guidelines document**** • A: ASSESSMENT: Influenza Type A (ICD 10 code J09) : influenza due to certain identified influenza viruses. • Influenza is difficult to diagnose based on symptoms, lab results are important (Hart, 2015). Julia has a positive RIDT for type A flu, which is 90-95% specific (Hart, 2015). This note does not contain all parts of the subjective section of a SOAP note. Review the next section of this PowerPoint, 511 Guidelines Document and the sample SOAP note at the end of this PPT to see a complete SOAP note subjective section.

  19. Post 2: The plan section P: PLAN 1. Medications Rx: Oseltamivir 75 mg Sig: 1 tab po q 12 hours x 5 days. Disp #10 tabs, no refills. (Hart, 2015; Epocrates, 2015) Early antiviral treatment, symptoms <48 hours, can shorten symptom duration and may reduce complications (Hart, 2015). Encourage patients to take OTC medications for cough, fever, pain and muscle aches (Dunphy et al, 2011; Hart, 2015). • Ibuprofen 600 mg po q 6-8 hours as needed for pain and/or fever, max of 2400 mg/day (Hart, 2015; Epocrates, 2015) • Dextromethorphan 60 mg po q 12 hours as needed for cough, max of 120 mg/day. (Hart, 2015; Epocrates, 2015) • (Influenza vaccine when better (Dunphy et al, 2011; Hart, 2015). 2. Additional diagnostic tests: additional testing needed only with severe symptoms as listed below (Hart, 2015) Note: each medication and step includes an intext citation for the scholarly source, this proves the plan is evidence based practice. Note that Epocrates is allowed for dosing but it not the primary reference for any medications or plan steps.

  20. Post 2 Plan Step 3 • 3. Education: • Cover your cough. The flu is spread through sneezing, coughing and respiratory secretions (Hart, 2015). • Flu symptoms typically last for 3-7days and get better without treatment in 5-10 days (Hart, 2015). • Rest and drink at least 8 eight ounce glasses of fluid each day (Dunphy et al, 2011). • Call office or return to clinic if symptoms become severe (fever, chest pain, SOB, worsening cough, increased mucus production) (Hart, 2015). • Unvaccinated family members should be vaccinated, can receive flu prophylaxis at same time (Dunphy et al, 2011).

  21. Post 2 and SOAP Note Steps 4 and 5 • 4. Referrals None at this time only needed with severe or progressive symptoms as listed above (Hart, 2015) • 5. Follow up. None necessary if getting progressively better (Dunphy et al, 2011). Call office or return to clinic if symptoms become severe as listed above (Hart, 2015). Follow up with PCP for RHM. • All SOAP notes should have all 5 steps listed.

  22. Post 3 the SOAP note* review the Guidelines document in Course Resources S: • Chief Complaint (CC): cold symptoms x 2 days, worsening. • History of present illness (HPI): O: I started to have cold symptoms yesterday, L & D: no information provided. C: included runny nose, watery eyes, cough and a headache. Was very tired last night and went to bed early. Julia felt even worse this afternoon: throat really hurts, very tired, legs ache feels cold, and can’t get warm. Julia did not go to school today and did not check her temperature. A: no information provided. R & T: Took Tylenol and Motrin for the headache, did not help, and has felt nauseous since she took the last dose of Motrin three hours ago. S: no information provided. • Past Medical History (PMH): vaccinations are up to date. , no allergies no medications • Family History (FH): one older and one younger sibling in good health. • Social History (SH): junior in high school, she gets good grades. She works part time at the mall in the food court. • Review of Systems (ROS) • Constitutional symptoms: feels cold, very tired, Eyes: watery eyes, Ears, nose, mouth and throat: runny nose and cough, sore throat, Gastrointestinal: nauseous, Musculoskeletal: body aches *Include only the information given in the case study, do not add any information to the case studies* *this is the SOAP note which is due in the dropbox by Sunday @11:59pm each week

  23. SOAP continued 0: Objective • VS: T 101.8, P 92, R 20, BP 104/62. Ht. 61.5 inches, weight 97 lbs. BMI: 18.3 (Calculate for all patients) • General: Alert, oriented but appears fatigued. Answers questions appropriately. HEENT: head normocephalic. Hair thick with distribution throughout scalp. Eyes: tearing bilaterally, Conjunctiva red bilaterally wit tearing noted. Eyes PERRLA, EOMs intact. Eyelids without erythema, no crusting noted on eyelashes. Ears: Tympanic membranes pearly gray, intact, with bubbles noted in right ear. Pinna and tragus nontender.  Nares with erythema, edematous with clear exudate noted.  Oropharynx moist, throat erythematous, tonsils 2+ bilaterally. Clear exudate noted. Teeth in good repair, no cavities noted. Sinuses nontender to palpation. Neck supple. Mild anterior cervical lymphadenopathy noted bilaterally. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored.  Gastrointestinal: Abdomen soft, nontender, bowel sounds auscultated in all four quadrants fields. No organomegaly noted. • Labs: RIDT: positive type A

  24. SOAP continued A: ASSESSMENT: Influenza Type A (ICD 10 code J09): influenza due to certain identified influenza viruses. • Influenza is difficult to diagnose based on symptoms, lab results are important (Hart, 2015). Julia has a positive RIDT for type A flu, which is 90-95% specific (Hart, 2015). • This is a complete rationale for the chosen diagnosis. Note that this section includes the diagnosis, and EBP citation which supports the diagnosis and the interpretation of the lab findings which confirm the diagnosis. • Note: differential diagnoses are not included in the SOAP note, only the chosen diagnosis.

  25. SOAP (continued) P: PLAN 1. Medications • Rx: Oseltamivir 75 mg Sig: 1 tab po q 12 hours x 5 days. Disp #10 tabs, no refills. (Hart, 2015;Epocrates,2015) Early antiviral treatment, symptoms <48 hours, can shorten symptom duration and may reduce complications (Hart, 2015). Encourage patients to take OTC medications for cough, fever, pain and muscle aches (Dunphy et al, 2011; Hart, 2015). • Ibuprofen 600 mg po q 6-8 hours as needed for pain and/or fever, max of 2400 mg/day (Hart, 2015;Epocrates,2015) • Dextromethorphan 60 mg po q 12 hours as needed for cough, max of 120 mg/day. (Hart, 2015;Epocrates,2015) • Influenza vaccine when better (Dunphy et al, 2011; Hart, 2015). 2. Additional diagnostic tests: additional testing needed only with severe symptoms as listed below (Hart, 2015)

  26. SOAP (Continued) 3. Education: • The flu is spread through sneezing, coughing and respiratory secretions (Hart, 2015). • Flu symptoms typically last for 3-7days and get better without treatment in 5-10 days (Hart, 2015). • Rest and drink at least 8 eight ounce of fluids each day (Dunphy et al, 2011). • Call office or return to clinic if symptoms become severe (fever, chest pain, SOB, worsening cough, increased mucus production) (Hart, 2015). • Unvaccinated family members should be vaccinated, can receive prophylaxis at same time (Dunphy et al, 2011). 4. Referrals None at this time only needed with severe or progressive symptoms as listed above (Hart, 2015) 5. Follow up. None necessary if getting progressively better (Dunphy et al, 2011). Call office or return to clinic if symptoms become severe as listed above (Hart, 2015). Follow up with PCP for RHM.

  27. References Dextromethorphan. (2015). In Epocrates Essentials for Apple iOS (Version 5.1) [Mobile application software]. Retrieved from http://www.epocrates.com/mobile/iphone/essentials Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: The art and science of advanced practice nursing (3rd Ed.). Retrieved from http://online.vitalsource.com Hart, A.M. (2015). Respecting influenza: An evidence-based overview for primary care nurse practitioners. JNP: The Journal for Nurse Practitioners (11), 1, 41-48. Ibuprofen. (2015). In Epocrates Essentials for Apple iOS (Version 5.1) [Mobile application software]. Retrieved from http://www.epocrates.com/mobile/iphone/essentials Oseltamivir (2015). In Epocrates Essentials for Apple iOS (Version 5.1) [Mobile application software]. Retrieved from http://www.epocrates.com/mobile/iphone/essentials

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