Comprehensive History and Physical SOAP Note

This is a SOAP Note that I have started. I basically need someone to finish the SOAP note starting from the Assessment and Plan of the note. Add a title page, Page numbers, in text citation, references. Keep the information that I have on the template. If you need to add to it, fine. This is a 41 year old female that is presented for her Annual Wellness. She is healthy without any problems.

Resources:

• Fowler, G. C. (2019). Pfenninger and Fowlers Procedures for Primary Care (4th ed.). Elsevier.
• Section 10, Obstetrics
• Chapter 162, Dilation and Curettage (pp. 10931099)
• Fanslow, J., Wise, M. R., & Marriott, J.(2019).
• . Obstetrics, Gynaecology & Reproductive Medicine, 29 (12), 342350. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.ogrm.2019.09.003

(Previously read in Week 2)

• Lockwood, C. J. (2019).
• . Contemporary OB/GYN, 64 (1), 2329. https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=134229869&site=ehost-live&scope=site&authtype=shib&custid=s6527200

(Previously read in Week 2)

• Document:

Practicum Resources

• Walden University Field Experience. (n.d.-a).
• . https://academicguides.waldenu.edu/fieldexperience/son/home
• Walden University Field Experience. (n.d.-c).
• Links to an external site.
• https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
• Walden University Field Experience. (n.d.-b).
• Links to an external site.
• https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
• (n.d.).
• Links 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.

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.).

• (n.d.). https://www.cancer.org/
• . (n.d.). https://www.acog.org/
• . (n.d.). https://www.nursingworld.org/
• (n.d.). https://www.cdc.gov/
• (2020). https://www.aanp.org/
• HealthyPeople 2030. (2020).
• Links to an external site.
• https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework
• (n.d.-b).
• https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P&searchterm=

Rubric:

PRAC_6552_Week10_Final_Evaluation

PRAC_6552_Week10_Final_Evaluation

CriteriaRatingsPtsThis criterion is linked to a Learning Outcome

Part 1: Preceptor submitted evaluation: Please use the preceptor evaluation average score to determine level of achievement*A score less than 3.0 will require a remediation plan at midterm evaluation *A score less than 3.0 will result in clinical failure and/or potential performance improvement opportunities at final evaluation

40 to >39.0 pts

Excellent

Preceptor submitted evaluation average score equals 4.0

39 to >29.0 pts

Good

Preceptor submitted evaluation average score ranges from 3.99-3.0

29 to >19.0 pts

Fair

Preceptor submitted evaluation average score ranges from 2.99-2.0

19 to >0 pts

Poor

Preceptor submitted evaluation average score ranges from 1.99-0.0

40 pts

This criterion is linked to a Learning Outcome

Part 2:Faculty Review of Overall Student Clinical Work Up to Evaluation Point: o Students overall communication is effective and professional. Student demonstrates professional behavior. *Student provides safe and competent patient care. * Student demonstrates an appropriate knowledge base for advanced practice. *Student applies appropriate evidence in managing patient care. *Student demonstrates initiative in seeking out new learning experiences, procedures, or treatment options. oDemonstrates Cultural Sensitivity with delivery of care.

40 to >29.0 pts

Excellent

*Preceptor expressed no concerns regarding student communication, professionalism, or dependability. … *Preceptor indicates student consistently provides safe and competent patient care. … *Students demonstrates outstanding knowledge base in their clinical encounters and clinical assignments. … *Student consistently applies appropriate evidence in patient care and clinical assignments. … *Student consistently demonstrates initiative in seeking out learning opportunities. … *Preceptor expresses student demonstrates exceptional knowledge and/or consistency of Cultural Competency and Awareness.

29 to >19.0 pts

Good

*Preceptor expressed minor concerns regarding student communication, professionalism, and dependability…. *Preceptor indicates student provides safe and competent patient care. … *Students demonstrates appropriate knowledge base in their clinical encounters and clinical assignments. … *Student applies appropriate evidence in patient care and clinical assignments. … *Student demonstrates initiative in seeking out learning opportunities. … *Preceptor expresses student demonstrates adequate knowledge and/or consistency of Cultural Competency and Awareness.

19 to >10.0 pts

Fair

*Preceptor expressed specific, detailed concerns regarding student communication, professionalism, and dependability. … Preceptor with specific, detailed concerns regarding safety or competent patient care. … *Students demonstrates inconsistent knowledge base in their clinical encounters and clinical assignments…. *Student inconsistently applies appropriate evidence in patient care and clinical assignments. … *Student inconsistently demonstrates initiative in seeking out learning opportunities. … *Preceptor expresses student demonstrates minimal knowledge and/or consistency of Cultural Competency and Awareness.

10 to >0 pts

Poor

*Preceptor indicated they would not precept student again or decides to terminate preceptor relationship during course. … *Preceptor expressed significant concerns regarding safety and competency in patient care. … *Students demonstrates inadequate knowledge base in their clinical encounters and clinical assignments. … *Student rarely applies appropriate evidence in patient care and clinical assignments. … *Student rarely demonstrates initiative in seeking out learning opportunities. … *Preceptor expresses student demonstrates lack of knowledge and/or consistency of Cultural Competency and Awareness.

40 pts

This criterion is linked to a Learning Outcome

o Follows Clinical Policies and Procedures:o Completes clinical in timely manner o Documents Meditrek data following course requirements o Respectful behaviorso Active participant in patient care with computer camera on for telehealth clinical (if applicable) o Facilitates preceptor contact for evaluationso Student maintains academic integrity with all Meditrek documentation and submitted assignments.

20 to >15.0 pts

Excellent

*Student follows clinical policies and procedures as set forth in Student Practicum Manual. … *If applicable, student is active in patient encounters with computer camera on 100% of time during telehealth sessions. … *Student consistently maintains HIPPA compliance and academic integrity with all Meditrek documentation and clinical related assignments.

15 to >10.0 pts

Good

*Student follows clinical policies and procedures 80 % of the time as set forth in Student Practicum Manual. … *If applicable, student is active in patient encounters with computer camera on 80% of time during telehealth sessions. … *Student maintains HIPPA compliance and academic integrity with all Meditrek documentation and clinical related assignments.

10 to >5.0 pts

Fair

*Student follows clinical policies and procedures 70 % of the time as set forth in Student Practicum Manual. … *If applicable, student is active in patient encounters with computer camera on 70% of time during telehealth sessions. … *Student with several concerns noted regarding academic integrity with all Meditrek documentation and clinical related assignments.

5 to >0 pts

Poor

*Student follows clinical policies and procedures 60%or less of the time as set forth in Student Practicum Manual. … *If applicable, student is active in patient encounters with computer camera on 60% or less of time during telehealth sessions…. *Student with significant concerns noted regarding academic integrity with all Meditrek documentation and clinical related assignments.

20 pts

Total Points: 100