Summative Assessment: Pediatric Comprehensive SOAP Note and Reflection – B.P.
This week, you learned about the pediatric assessment and how the head-to-toe examination differs in the infant, child, and adult. In this summative assessment, you create a comprehensive SOAP note focused on B.P., a 7-year-old whose parents are concerned about his short stature and write a reflection addressing potential barriers to care and evidence-based practices related to the diagnoses. Complete Parts 1 and 2 below.
Part 1: SOAP Note
Read the B.P. Scenario.
To document your SOAP note for B.P.
Use this template:
SOAP Note Template.docx
And this structure guide:
SOAP Note Stucture Guide.docx
Reflection Template
Template – Reflection.docx
Make sure to review the 10 charts in Set 2: Clinical Charts With 3rd and 97th Percentiles from the National Center for Health Statistics and reference the appropriate chart within the SOAP note.
The assessment and plan sections will not be graded but should be completed to ensure proper documentation of a complete SOAP note. You will also use this information to complete your E&M coding for the visit. Make sure to do the following:
Document all relevant information using appropriate terminology.
List the appropriate ICD-10 codes and E&M codes for the diagnoses.
Part 2: Reflection
Now that you have completed your SOAP note for B.P., it is time for reflection. This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives.
Write a 700-word reflection providing rationale for your completed SOAP note, with consideration for the interview information provided in the patient scenario. Address the following in your reflection:
Locate and review at least 1 current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis. Provide a brief summary of the article(s). DO NOT EXCEED 800 WORDS.
Identify a minimum of 2 barriers to quality health care the patient can potentially experience per the information provided in the interview (e.g., cultural, linguistic, economic, previous conditions).
Explain how you, as the nurse practitioner, can address these barriers to improve the quality of care the patient receives.
Reference a minimum of 2 peer-reviewed articles to support your reflection.
Format your citations according to APA guidelines.
Submit your assessment.
NOTE: SEE THE UPLOAD FILES WITH THE INSTRUCTIONS FOR THE ASSIGNMENTS and SCHOOL READING CHAPTERS AND REFERENCE LINK.
Set 2: Clinical Charts With 3rd and 97th Percentiles
Bickley, L. S. (2020). <i>Bates’ guide to physical examination and history taking</i> (13th ed.). Wolters Kluwer Health. Ch 25,pp1108 – 1189
( PLEASE, I SPECIFY FOR Bernard -5251 to do my assignments) . Part 1- 3pages and Part 2 – 3pages.
Set 2: Clinical Charts With 3rd and 97th Percentiles
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