Patient histories are a building block of the diagnosis and treatment

Episodic Visit: Gynecology Focused Note

Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses   can piece together facts to construct a relevant history that can lead to assessment and treatment.

For this Focused Note Assignment, you will select a patient with gynecologic conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.

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

· Fowler, G. C. (2019).  Pfenninger and Fowler’s Procedures for Primary Care (4th ed.). Elsevier. 

· Chapter 136, “Insertion and Removal of Nexplanon” (pp. 946–951)

· Chapter 137, “Pessaries” (pp. 952–959)

· Chapter 138, “Treatment of Noncervical Condylomata Acuminata” (pp. 960–969)

· Chapter 139, “Vulvar Biopsy” (pp. 970–973)

Practicum Resources 

· Walden University Field Experience.Links to an external site.  (n.d.-a). ? Field experience: College of Nursing.Links to an external site. ?https://academicguides.waldenu.edu/fieldexperience/son/home

· Walden University Field Experience. (n.d.-c).  Student practicum resources: NP student orientation .Links to an external site.  https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation

· Walden University Field Experience. (n.d.-b).  MSN nurse practitioner practicum manual . Retrieved fromLinks to an external site.  https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments

· HSoft Corporation. (n.d.).  Meditrek Links to an external site. . https://edu.meditrek.com/Default.html  Note: Use this website to log in to Meditrek to report your clinical hours and patient encounters.

· Document:  Focused SOAP Note Template (Word document) Download Focused SOAP Note Template (Word document)

Clinical Guideline Resources 

· As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for the CDC -zika in pregnancy, etc.).

· American College of Obstetricians and Gynecologists.Links to an external site.  (n.d.). https://www.acog.org/

· American Cancer Society.Links to an external site.  (n.d.). https://www.cancer.org/  

· ANA Enterprise.Links to an external site.  (n.d.). https://www.nursingworld.org/

· Centers for Disease Control and Prevention.Links to an external site.  (n.d.). https://www.cdc.gov/ 

· HealthyPeople 2030. (2020). Healthy People 2030 framework.Links to an external site. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework

· The American Association of Nurse Practitioners.Links to an external site.  (2020). https://www.aanp.org/

· U.S. Preventive Services Task Force. (n.d.-b).  Search and filter all recommendation topics .Links to an external site.  https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P&searchterm=

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 Focused SOAP 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. With this patient in mind, address the following in your Focused Note Template.

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 four 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?

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