nu611 clinical decision making week 6- discussion

Applying Scholary Inquiry

Instructions:

Please use this SOAP Note example for this discussion:

Post a discussion constructed as the ‘P’ (treatment plan) that completes the partial SOAP note accessed through the link above.

Include in the discussion:

  1. Your treatment “Plan” for the first two diagnoses (see note below on how to structure the ‘P’)
  2. Citations for each of the evidence-based practice (EBP) interventions included in your Plan
  3. For each article you cited in support of an element of the Plan provide your thoughts about the strength of the evidence presented in the article(s)

Plan (P):

These are the interventions that relate to each individual, numbered diagnosis.

Document individual plans directly after each corresponding assessment (Ex. Assessment­ Plan). Address the following aspects (they should be separated out as listed below):

Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint

Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications.

Educational: information clients need in order to address their health problems. Include follow­ up care. Anticipatory guidance and counseling.

Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.

NOTE: please input N/A where appropriate for the above 4 categories, do not assume that your clinical faculty person will know it was not applicable.

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