Wk 7 – Summative Assessment: Comprehensive History and Physical: Maria Álvarez
Exam Content
You will be completing an advanced health assessment by completing a comprehensive SOAP note and then writing a reflection about the assessment, including evidence-based practices related to the diagnoses. Your assessment will be of Maria Álvarez, who is coming in for a well-woman visit. Make sure you use the appropriate codes for the patient’s age and type of visit.
Part 1: SOAP Note
Review the Maria Álvarez scenario.
Use the SOAP Note Template and the SOAP Note Structure Guide to develop the documentation needed to complete your SOAP note.
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:
Document all relevant information using appropriate terminology.
List the appropriate ICD-10 codes and E&M codes using the diagnoses provided.
Part 2: Reflection
Excellent work! Now that you have completed your SOAP note for Maria Álvarez, 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 1000- to 1100-word reflection providing rationale for your completed SOAP note that does the following:
Discuss which E&M codes are appropriate for this case and why.
Locate and then discuss a current evidence-based article about evidence-based guidelines or new research relating to each diagnosis. Provide a brief summary of the article(s) in your reflection.
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 an NP can address these barriers to improve the quality of care the patient receives. Use a minimum of 2 peer-reviewed articles to support your answers.
Note: Consider the interview information provided in the patient scenario when writing your reflection.
Cite the references used to support your assignment.
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 15
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