Case Study Assignment

Guidelines with Scoring Rubric

Purpose

The purpose of this case study assignment is to

1) Analyze provided subjective and objective information to diagnose and develop a management plan for the case study patient.

2) Apply national diabetes guidelines to case study patient management plan.

3) Demonstrate mastery of SOAP note writing.

Course Outcomes

Through this assignment, the student will demonstrate the ability to:

1. Employ appropriate health promotion guidelines and disease prevention strategies in the management of mature and aging individuals and families.

2. Formulate appropriate diagnoses and evidence-based plans of care for mature and aging individuals and families using subjective and objective data.

3. Incorporate unique patient cultural preferences, values, and health beliefs in the care of mature and aging individuals and families

4. Integrate theory and evidence based practice in the care of mature and aging individuals and their families

6. Conduct pharmacologic assessment addressing polypharmacy, drug interactions and other adverse events in the care of mature and aging individuals and their families.

7. Apply evidence-based screening tools to perform functional assessments with aging individuals and their families as appropriate.

Due Date: Sunday 11:59 p.m. MT at the end of Week 5

Total Points Possible: 200 points

Preparing the Assignment

The assignment is a paper, which is to be written in APA format using the provided assignment template. The paper shall not exceed 20 pages.

Review the attached patient visit information. You are provided with the subjective and objective exam findings. As the provider, you are to diagnose the case study patient and develop the management plan for this case study patient.

Use the provided case study template for your paper. Review the APA Manual to adhere to APA formatting.

Introduction: briefly discuss the purpose of this paper.

Assessment: review the provided case study information.

Identify the primary, secondary and differential diagnoses for the patient. Use the 601 Clinical SOAP note format as a guide to develop your diagnoses.

Each diagnosis will include the following information:

1. ICD 10 code.

2. A brief pathophysiology statement which is no longer that two sentences, paraphrased and includes common signs and symptoms of the diagnosis and proper citation.

3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentence statement, which links the subjective and objective findings (including lab data and interpretation).

4. A rationale statement, which summarizes why the diagnosis was chosen.

5. Do not include quotes, paraphrase all scholarly information and provide an in text citation to your scholarly reference. Use the Reference Guidelines document for information on scholarly references.

Plan (there are five (5) sections to the management plan)

1. Diagnostics. List all labs and diagnostic test you would like to order. Each test includes a rationale statement following the listed lab, which includes the diagnosis for the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited.

2. Medications: Each medication is listed in prescription format. Each prescribed and OTC medication is linked to a specific diagnosis and includes a paraphrased EBP rationale for prescribing.

3. Education: section includes personalized detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized appropriate exercise recommendations and warning sign for diagnosis and medications if applicable. All education steps are linked to a diagnosis, paraphrased, and include a paraphrased EBP rationale. Review the NR601 Clinical SOAP note guideline for more detailed information.

4. Referrals: any recommended referrals are appropriate to the patient diagnosis and current condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale with in text citation.

5. Follow up: Follow up includes a specific time, not a time range, to return to PCP office for next scheduled appointment. Includes EBP rationale with in text citation.

Medication costs: in this section students will research the costs of all prescribed and OTC monthly medications that you have prescribed and that the patient is currently taking that you would like to continue. Students may use Good Rx, Epocrates or another resource (students may use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications and provide the total costs of the month’s medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice.

SOAP note: A focused SOAP note, written on a separate page, follows the assignment. The SOAP note is written following the provided Clinical SOAP note format.

· The subjective section is organized to follow the Clinical SOAP note format. The ROS is focused; only pertinent body systems are included. Only provided information is included in the ROS. No additional data is added.

· The objective section is maintained as written, no additional information is added.

· The assessment section includes only the diagnoses and ICD 10 codes. Diagnosed are labeled as primary, secondary or differential diagnoses. Rationale is not included in the SOAP note.

· The plan includes five sections. Rationale is not included in the SOAP note.

The assignment will be submitted through TurnItIn. Due to the common language in a large group assignment, it is possible that similarity scores can exceed 25%. It is the student’s responsibility to review the TII paper and assure that sections of original work contain low similarity. If there are concerns, please contact your instructor.

Category	Points	%	Description
Assessment	50	25	Each diagnosis, primary, secondary and differential, includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference. Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to your patient. Pertinent lab results are interpreted within the rationale statement.
Evidence-Based Practice (EBP)	50	25	National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later (or article related to 2018 Guidelines) are used to support the primary diagnosis and develop the plan. Every diagnosis rationale must include an in text citation to a scholarly reference. Each action step or order within all plan sections includes an in text citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included. Reference interpretation is accurate. Diagnoses plans are consistent with the guideline recommendations.
Plan: diagnostics	10	5	All ordered diagnostics tests are linked to a diagnosis and include a paraphrased EBP rationale with citation. Each diagnosis is included in the plan. Plans are consistent with the guideline recommendations or scholarly reference.
Plan: medications	10	5	Each prescribed and OTC medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale. Diagnosis is clearly stated in the rationale statement. Plans are consistent with the guideline recommendations or scholarly reference
Plan: education	10	5	All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes personalized detailed education on diagnoses, medications, diet, exercise and warning signs. Personalized diet and exercise recommendations are included. Plans are consistent with the guideline recommendations or scholarly reference.
Plan: Referrals	10	5	All recommended referrals are appropriate for the patient diagnosis; each referral is linked to a specific diagnosis and includes a paraphrased EBP rationale. Plans are consistent with the guideline recommendations or scholarly reference
Plan: Follow up	10	5	Follow up includes a specific time/date to return to PCP office. Includes EBP rationale with in text citation. Only follow up information is listed in this section. Plans are EBP and consistent with the guideline recommendations.
Medication costs	10	5	Monthly medication costs are calculated and a total cost for the month’s medication is included. All medications including OTCs are included. Medication cost citation is included. Summary/reflection statement is included.
SOAP note	20	10	This SOAP note is an example of a patient chart entry. SOAP note included at end of assignment before the reference page. SOAP note includes all elements and is formatted exactly as described in the Clinical SOAP note guidelines document. Rationales are not included. Only provided information is included in the SOAP note.
Grammar, Syntax, APA	10	5	APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors. All referenced information is cited, “according to” is not used.
Organization	10	5	Paper is developed in a logical, meaningful, and understandable sequence using the provided assignment template Rationale length does not exceed template directions. SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format. The paper does not exceed 20 pages.
Total	200	100	A quality assignment will meet or exceed all of the above requirements.

Case Study Assignment