Episodic Visit: Gynecology Focused Note
Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses can piece together facts to construct a relevant history that can lead to assessment and treatment.
For this Focused Note Assignment, you will select a patient with gynecologic conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.
Note: 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.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
Resources
- Fowler, G. C. (2019). Pfenninger and Fowler’s Procedures for Primary Care(4th ed.). Elsevier.
- Chapter 136, “Insertion and Removal of Nexplanon” (pp. 946–951)
- Chapter 137, “Pessaries” (pp. 952–959)
- Chapter 138, “Treatment of Noncervical Condylomata Acuminata” (pp. 960–969)
- Chapter 139, “Vulvar Biopsy” (pp. 970–973)
Practicum Resources
- Walden University Field Experience.Links to an external site.(n.d.-a). Field experience: College of Nursing.Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/home
- Walden University Field Experience. (n.d.-c). Student practicum resources: NP student orientation.Links to an external site.https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
- Walden University Field Experience. (n.d.-b). MSN nurse practitioner practicum manual. Retrieved fromLinks to an external site.https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
- HSoft Corporation. (n.d.). MeditrekLinks to an external site.. https://edu.meditrek.com/Default.html
Note:Use this website to log in to Meditrek to report your clinical hours and patient encounters. - Document: Focused SOAP Note Template (Word document)Download Focused SOAP Note Template (Word document)
Clinical Guideline Resources
- As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for the CDC -zika in pregnancy, etc.).
- American College of Obstetricians and Gynecologists.Links to an external site.(n.d.). https://www.acog.org/
- American Cancer Society.Links to an external site.(n.d.). https://www.cancer.org/
- ANA Enterprise.Links to an external site.(n.d.). https://www.nursingworld.org/
- Centers for Disease Control and Prevention.Links to an external site.(n.d.). https://www.cdc.gov/
- HealthyPeople 2030. (2020).Healthy People 2030 framework.Links to an external site.
https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework - The American Association of Nurse Practitioners.Links to an external site.(2020). https://www.aanp.org/
- S. Preventive Services Task Force. (n.d.-b). Search and filter all recommendation topics.Links to an external site.https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P&searchterm=
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To prepare:
- Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.
- Select a patient that you examined during the last three weeks. With this patient in mind, address the following in your Focused Note Template.
Assignment
- Subjective:What details did the patient provide regarding her personal and medical history?
- Objective:What observations did you make during the physical assessment?
- Assessment:What were your differential diagnoses? Provide a minimum of four possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: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.
- Reflection notes:What would you do differently in a similar patient evaluation?