Episodic\/Focused Note: Musculoskeletal Focused Note Assignment Example<\/p>\n
Patient Information:<\/p>\n
Initials: J.S.<\/p>\n
Age: 52<\/p>\n
Sex: Female<\/p>\n
Race: Caucasian<\/p>\n
S. (Subjective)<\/p>\n
CC: “My right knee has been hurting for weeks.”<\/p>\n
HPI: A 52-year-old Caucasian female presents with a chief complaint of right knee pain for the past 6 weeks. The pain is described as a dull ache that worsens with activity, particularly climbing stairs and walking long distances. She reports no history of trauma to the knee. The pain is located in the medial aspect of the knee and is rated as a 5\/10 on the pain scale. She denies any locking, clicking, or swelling. She reports taking over-the-counter ibuprofen for pain relief with some temporary improvement. She denies any history of knee injuries or surgeries.<\/p>\n
Current Medications: Ibuprofen 200mg every 6 hours as needed for pain.<\/p>\n
Allergies: None reported.<\/p>\n
PMHx: Hypertension, well-controlled with medication. Appendectomy at age 18.<\/p>\n
Soc Hx: Works as a cashier at a grocery store. Enjoys gardening and walking. Lives with her husband and two adult children. No tobacco or alcohol use.<\/p>\n
Fam Hx: Mother has osteoarthritis.<\/p>\n
ROS:<\/p>\n
General: No fever, chills, weight loss, or fatigue.<\/p>\n
HEENT: No headache, dizziness, or visual changes.<\/p>\n
Cardiovascular: No chest pain, palpitations, or edema.<\/p>\n
Respiratory: No cough, shortness of breath, or wheezing.<\/p>\n
Gastrointestinal: No nausea, vomiting, or diarrhea.<\/p>\n
Genitourinary: No urinary frequency or burning.<\/p>\n
Neurological: No numbness or tingling.<\/p>\n
Musculoskeletal: Pain in right knee.<\/p>\n
Hematologic: No bleeding or bruising.<\/p>\n
Lymphatic: No swollen lymph nodes.<\/p>\n
. Psychiatric: No depression or anxiety.<\/p>\n
Endocrine: No sweating or heat intolerance.<\/p>\n
O. (Objective)<\/p>\n
General: Alert and oriented x3. In no apparent distress.<\/p>\n
HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light.<\/p>\n
Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops.<\/p>\n
Respiratory: Clear to auscultation bilaterally.<\/p>\n
Gastrointestinal: Soft, non-tender abdomen.<\/p>\n
Musculoskeletal: Right knee: Tenderness to palpation over medial joint line. Full range of motion with pain. No swelling.<\/p>\n
A. (Assessment)<\/p>\n
Primary Diagnosis: Likely osteoarthritis of the right knee.<\/p>\n
Differential Diagnoses:<\/p>\n
Secondarily: Meniscus tear.<\/p>\n
Third: Referred pain from the hip.<\/p>\n
P. (Plan)<\/p>\n
Diagnostic Studies: X-ray of the right knee.<\/p>\n
Treatment:<\/p>\n
Pharmacologic: Continue ibuprofen as needed.<\/p>\n
Non-pharmacologic: Ice and compression. Physical therapy referral for strengthening exercises.<\/p>\n
Follow-up: Follow-up in 2 weeks.<\/p>\n
Reflection:<\/p>\n
This case highlights the importance of a thorough history and physical exam in diagnosing musculoskeletal conditions. I was able to narrow down the differential diagnoses based on the patient’s history and physical exam findings. I will continue to refine my skills in physical exam techniques to improve my diagnostic accuracy.<\/p>\n
References<\/p>\n
Keywords: Musculoskeletal, osteoarthritis, knee pain, physical exam, diagnosis, treatment plan, patient education.<\/p>\n
==========<\/p>\n
EPISODIC VISIT: MUSCULOSKELETAL FOCUSED NOTE
\nFor this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks. You will complete your third Episodic\/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, previous medical history (PMH), socio-economic, cultural background, etc. In this week\u2019s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.
\nNote: 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.
\nNote: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.<\/p>\n
RESOURCES<\/p>\n
Be sure to review the Learning Resources before completing this activity.
\nClick the weekly resources link to access the resources.
\nWEEKLY RESOURCES
\nTo prepare:
\n\u2022\tUse the Episodic\/Focused Note Template found in the Learning Resources for this week to complete this assignment.
\n\u2022\tSelect a patient that you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following in a Focused Note:
\nAssignment:
\n\u2022\tSubjective: What details did the patient provide regarding her personal and medical history?
\n\u2022\tObjective: What observations did you make during the physical assessment?
\n\u2022\tAssessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
\n\u2022\tPlan: 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.
\n\u2022\tReflection notes: What would you do differently in a similar patient evaluation?
\nNote: Your Focused Note Assignment must be signed by Day 7 of Week 9.<\/p>\n
BY DAY 7
\nSubmit your Episodic\/Focused Note Assignment. <\/p>\n
(Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf\/images of each page that is initialed and signed by your preceptor by Day 7 of Week 9.)<\/p>\n
SUBMISSION INFORMATION
\nBefore submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
\n1.\tTo submit your completed assignment, save your Assignment as WK9Assgn2_LastName_Firstinitial
\n2.\tThen, click on Start Assignment near the top of the page.
\n3.\tNext, click on Upload File and select Submit Assignment for review.<\/p>\n
Rubric
\nPRAC_6531_Week9_Assignment2_Rubric
\nPRAC_6531_Week9_Assignment2_Rubric
\nCriteria\tRatings\tPts
\nThis criterion is linked to a Learning OutcomeOrganization of Write-up\t10 to >6.0 pts
\nExcellent
\nAll information organized in logical sequence; follows acceptable format and utilizes expected headings.\t6 to >3.0 pts
\nGood
\nInformation generally organized in logical sequence; follows acceptable format and utilizes expected headings.\t3 to >0.0 pts
\nFair
\nErrors in format; information intermittently organized. Headings are used some of the time.\t0 pts
\nPoor
\nErrors in format; information disorganized. Headings are not used appropriately.
\n\t10 pts
\nThis criterion is linked to a Learning OutcomeThoroughness of History\t20 to >15.0 pts
\nExcellent
\nThoroughly documents all pertinent history components for type of note; includes critical as well as supportive information.\t15 to >11.0 pts
\nGood
\nDocuments most pertinent examination components.\t11 to >7.0 pts
\nFair
\nDocuments some pertinent examination components.\t7 to >0 pts
\nPoor
\nPhysical examination cursory; misses several pertinent components.
\n\t20 pts
\nThis criterion is linked to a Learning OutcomeHistory of Present Illness\t10 to >6.0 pts
\nExcellent
\nThoroughly documents all 8 aspects of HPI and pertinent other data relevant to chief complaint. Includes critical as well as supportive information.\t6 to >4.0 pts
\nGood
\nDocuments at least 6 aspects of the HPI and pertinent other data relevant to chief complaint. Includes critical information.\t4 to >2.0 pts
\nFair
\nDocuments at least 4 aspects of HPI and some data pertinent to chief complaint. Lacks some critical information or rambling in history.\t2 to >0 pts
\nPoor
\nMissing many aspects of HPI and pertinent data. Critical information missing.
\n\t10 pts
\nThis criterion is linked to a Learning OutcomeThoroughness of Physical Exam\t10 to >7.0 pts
\nExcellent
\nThoroughly documents all pertinent examination components for type of note.\t7 to >4.0 pts
\nGood
\nDocuments most pertinent examination components.\t4 to >2.0 pts
\nFair
\nDocuments some pertinent examination components.\t2 to >0 pts
\nPoor
\nPhysical examination cursory; misses several pertinent components.
\n\t10 pts
\nThis criterion is linked to a Learning OutcomeDiagnostic Reasoning\t10 to >7.0 pts
\nExcellent
\nAssessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests.\t7 to >4.0 pts
\nGood
\nAssessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.\t4 to >2.0 pts
\nFair
\nAssessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests.\t2 to >0 pts
\nPoor
\nAssessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests.
\n\t10 pts
\nThis criterion is linked to a Learning OutcomeTreatment Plan\/Patient Education\t20 to >15.0 pts
\nExcellent
\nTreatment plan addresses all issues raised by diagnoses, excellent insight into patient\u2019s needs. Medications prescribed are appropriate and full prescription is included. Evidence based decisions. Cost effective treatment.\t15 to >10.0 pts
\nGood
\nTreatment plan addresses most issues raised by diagnoses. Medications prescribed are appropriate but include 1 or 2 error in writing prescription.\t10 to >5.0 pts
\nFair
\nTreatment plan fails to address most issues raised by diagnoses. Medications are inappropriate or include 3 or more errors in writing prescription.\t5 to >0 pts
\nPoor
\nMinimal treatment plan addressed. Medications are inappropriate or poorly written prescription.
\n\t20 pts
\nThis criterion is linked to a Learning OutcomePatient Education \/ Follow Up \/ Reflection\t10 to >8.0 pts
\nExcellent
\nPatient education addresses all issues raised by diagnoses, excellent insight into patient\u2019s needs. Follow up plan in appropriate and reflects acuity of illness. Reflection is thoughtful and in depth.\t8 to >5.0 pts
\nGood
\nPatient education addresses most issues raised by diagnoses. Follow up plan is appropriate but lacks specifics Reflection is thoughtful and in depth.\t5 to >3.0 pts
\nFair
\nPatient education fails to address most issues raised by diagnoses. Follow up plan is lacking specifics or is inappropriate for patient acuity. Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.\t3 to >0 pts
\nPoor
\nMinimal patient education addressed. Follow up plan is inappropriate Reflection is absent.
\n\t10 pts
\nThis criterion is linked to a Learning OutcomeWritten Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation. Professional language utilized\t5 pts
\nExcellent
\nUses correct grammar, spelling, and punctuation with no errors. Professional language utilized.\t4 pts
\nGood
\nContains a few (1-2) grammar, spelling, and punctuation errors. Contains a few errors (1 or 2) in professional language use.\t2 pts
\nFair
\nContains several (3-4) grammar, spelling, and punctuation errors. Contains several errors (3 -4) in professional language use.\t0 pts
\nPoor
\nContains many (\u2265 5) grammar, spelling, and punctuation errors that interfere with the reader\u2019s understanding. Contains many errors in professional language use.
\n\t5 pts
\nThis criterion is linked to a Learning OutcomeScholarly References and Clinical Practice Guidelines. The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Clinical practice guidelines are included if applicable.\t5 pts
\nExcellent
\nContains parenthetical\/in-text citations and at least 3 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.\t4 pts
\nGood
\nContains parenthetical\/in-text citations and at least 2 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.\t2 pts
\nFair
\nContains parenthetical\/in-text citations and at least 1 evidenced based reference less than 5 years old is listed. Clinical practice guidelines are not cited if applicable.\t0 pts
\nPoor
\nContains no parenthetical\/in-text citations and 0 evidenced based references listed. Clinical practice guidelines are not cited if applicable.
\n\t5 pts
\nTotal Points: 100<\/p>\n","protected":false},"excerpt":{"rendered":"
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