Wk 3 – Summative Assessment: Episodic SOAP Note and Reflection – Danny Rivera
This week, you learned about the pediatric assessment and completed the Shadow Health focused exam of Danny Rivera. In this summative assessment, you create an episodic SOAP note for Danny Rivera 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
Review the Danny Rivera scenario in the Wk 3 – Shadow Health Focused Exam: Cough assignment.
To document your SOAP note for Danny Rivera:
Use this template:
SOAP Note Template.docx
Use this structure guide:
SOAP Note Stucture Guide.docx
The assessment and plan sections will not be graded but should be completed to ensure 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 (with consideration for the patient’s age and type of visit).
Part 2: Reflection
Now that you have completed your SOAP note for Danny Rivera, 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). References for scholarly papers are < 5 yo. 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.
Bickley, L. S. (2020). <i>Bates’ guide to physical examination and history taking</i> (13th ed.). Wolters Kluwer Health. Ch 25, pp1037 – 1107. Read pp 1037 – 1107 "Children: Infancy Through Adolescence"
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