Instructions
FOR AGPCNP STUDENTS EPISODIC VISIT: COMMON GYNECOLOGIC HEALTH CONDITIONS FOCUSED NOTE FOR FNP STUDENTS OB EPISODIC VISIT: 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 common gynecologic health 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.
TO PREPARE
• Use the Focused SOAP Note Template found in this week’s Learning Resources to complete this Assignment.
• For AGPCNP students select a patient with common gynecologic health conditions whom you examined during the last three weeks in your practicum experience. For FNP students select a OB patient that you have examined in the last three weeks in your practicum experience. 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 three 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?