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**files (2)** – ## MSN5550SignatureAssignment5.pdf – ## SignatureAssignmentRubric7.pdf **## MSN5550SignatureAssignment5.pdf** MSN 5550 Health Promotion: Prevention of Disease Case Study Module 2 Instructions: Read the following case study and answer the reflective questions. Please provide evidence-…
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– ## MSN5550SignatureAssignment5.pdf
– ## SignatureAssignmentRubric7.pdf
**## MSN5550SignatureAssignment5.pdf**
MSN 5550 Health Promotion: Prevention of Disease
Case Study Module 2
Instructions: Read the following case study and answer the reflective questions. Please provide
evidence-based rationales for your answers. APA, 7th ed. must be followed.
Due: Saturday by 23:59 pm
CASE STUDY: An Older Immigrant Couple: Mr. and Mrs. Arahan
Mr. and Mrs. Arahan, an older couple in their seventies, have been living with their oldest daughter,
her husband of 15 years, and their two children, ages 12 and 14. They all live in a middle-income
neighborhood in a suburb of a metropolitan city. Mr. and Mrs. Arahan are both college educated and
worked full-time while they were in their native country. In addition, Mr. Arahan, the only offspring
of wealthy parents, inherited a substantial amount of money and real estate. Their daughter came to
the United States as a registered nurse and met her husband, a drug company representative. The
older couple moved to the United States when their daughter became a U.S. citizen and petitioned
them as immigrants. Since the couple was facing retirement, they welcomed the opportunity to come
to the United States.
The Arahans found life in the United States different from that in their home country, but their
adjustment was not as difficult because both were healthy and spoke English fluently. Most of their
time was spent taking care of their two grandchildren and the house. As the grandchildren grew older,
the older couple found that they had more spare time. The daughter and her husband advanced in
their careers and spent a great deal more time at their jobs. There were few family dinners during
the week. On weekends, the daughter, her husband, and their children socialized with their own
friends. The couple began to feel isolated and longed for a more active life.
Mr. and Mrs. Arahan began to think that perhaps they should return to the home country, where
they still had relatives and friends. However, political and economic issues would have made it
difficult for them to live there. Besides, they had become accustomed to the way of life in the United
States with all the modern conveniences and abundance of goods that were difficult to obtain in their
country. However, they also became concerned that they might not be able to tolerate the winter
months and that minor health problems might worsen as they aged. They wondered who would take
care of them if they became very frail and where they would live, knowing that their daughter had
only saved money for their grandchildren’s college education. They expressed their sentiments to
their daughter, who became very concerned about how her parents were feeling.
This older couple had been attending church on a regular basis, but had never been active in other
church-related activities. The church bulletin announced the establishment of parish nursing with
two retired registered nurses as volunteers. The couple attended the first opening of the parish clinic.
Here, they met one of the registered nurses, who had a short discussion with them about the services
offered. The registered nurse had spent a great deal of her working years as a community health
nurse. She informed Mr. and Mrs. Arahan of her availability to help them resolve any health-related
issues.
Reflective Questions
1. What strategies could be suggested for this older adult couple to enhance their quality of life?
2. What community resources can they utilize?
3. What can the daughter and her family do to address the feelings of isolation of the older couple?
4. What health promotion activities can ensure a healthy lifestyle for them?
– CASE STUDY: An Older Immigrant Couple: Mr. and Mrs. Arahan
– Reflective Questions
**## SignatureAssignmentRubric7.pdf**
1
MSN5550 Health Promotion: Prevention of Disease
Case Study Rubric
Criteria Unsatisfactory-Beginning Developing Accomplished Exemplary Total
Ideas,
Arguments,
& Analysis
0-30 points 35-39 points 40-44 points 45-50 points /50
Ideas expressed lack an
understanding of the case
study. Comments are
irrelevant, off-topic, and/or
confusing to follow.
Viewpoint, if given, is not
supported with evidence or
examples.
Ideas expressed in case
study show a minimal
understanding of the topic.
Comments are general in
nature and/or occasionally
may not be relevant.
Rehashes or summarizes
ideas with limited analysis,
original thought, and/or
supported viewpoints.
Ideas expressed in case
study are mostly substantive
and relevant to topic; some
original thought.
Demonstrates logical
thinking, reasoning, and/or
analysis for most part.
Viewpoint is supported with
evidence and/or examples.
Ideas expressed in case
study include original
thought, substantial
depth, and are relevant to
topic. Responses show
strong logical thinking,
reasoning, and analysis
with evidence and
examples. Construction of
new meaning and insights
are evident.
Connection
to Course
Materials
0-13 points 14-15 points 16-17 points 18-20 points /20
No connections are made
to readings or other course
materials (lectures, media,
resources, etc.), and/or if
made, are not clearly
stated and are largely
personal opinions.
Minimal direct connections
are made to readings and/or
other course materials
(lectures, media, resources,
etc.). Connections are
largely inferred and
somewhat unclear at times.
Some direct connections are
made to readings and/or
other course materials
(lectures, media, resources,
etc.) and are clearly stated
for the most part.
Strong, direct connections
are made to readings
and/or other course
materials (lectures, media,
resources, etc.) and are
clearly stated.
Content and
Pedagogical
Knowledge
0-13 points 14-15 points 16-17 points 18-20 points /20
The case study response
displays a lack of
comprehension of the
assignment.
The case study responses
are partially addressed.
There are components of
the assignment not
addressed.
The case study response
demonstrates
comprehension of
assignment expectations,
however, is missing
responses to some of the
case study questions.
The case study response
demonstrates
comprehension of
assignment expectations
and includes the essential
components of the
assignment.
2
Case Study Rubric (continued)
Criteria Unsatisfactory-Beginning Developing Accomplished Exemplary Total
Writing
Quality
0-6 points 7 points 8 points 9-10 points /10
Responses to case study
show a below average/poor
writing style that lacks
standard English, and/or is
difficult for readers to
follow. Contains frequent
errors in grammar,
punctuation, usage, and
spelling.
Responses to case study
show an average and/or
casual writing style using
standard English that is
generally clear but contains
some errors in grammar,
punctuation, usage, and
spelling.
Responses to case study
show above average writing
style that is clear using
standard English with minor
errors in grammar,
punctuation, usage, and/or
spelling.
Responses to case study
are well written and
clearly articulated using
standard English,
characterized by elements
of a strong writing style
with correct grammar,
punctuation, usage, and
spelling.
TOTAL POINTS (sum of Criteria) /100
Source: Rubric by Denise Kreiger, Instructional Design/Technology Services, SC&I, Rutgers, 3/2014
– Source: Rubric by Denise Kreiger, Instructional Design/Technology Services, SC&I, Rutgers, 3/2014
**## SignatureAssignmentRubric7.pdf**
1
MSN5550 Health Promotion: Prevention of Disease
Case Study Rubric
Criteria Unsatisfactory-Beginning Developing Accomplished Exemplary Total
Ideas,
Arguments,
& Analysis
0-30 points 35-39 points 40-44 points 45-50 points /50
Ideas expressed lack an
understanding of the case
study. Comments are
irrelevant, off-topic, and/or
confusing to follow.
Viewpoint, if given, is not
supported with evidence or
examples.
Ideas expressed in case
study show a minimal
understanding of the topic.
Comments are general in
nature and/or occasionally
may not be relevant.
Rehashes or summarizes
ideas with limited analysis,
original thought, and/or
supported viewpoints.
Ideas expressed in case
study are mostly substantive
and relevant to topic; some
original thought.
Demonstrates logical
thinking, reasoning, and/or
analysis for most part.
Viewpoint is supported with
evidence and/or examples.
Ideas expressed in case
study include original
thought, substantial
depth, and are relevant to
topic. Responses show
strong logical thinking,
reasoning, and analysis
with evidence and
examples. Construction of
new meaning and insights
are evident.
Connection
to Course
Materials
0-13 points 14-15 points 16-17 points 18-20 points /20
No connections are made
to readings or other course
materials (lectures, media,
resources, etc.), and/or if
made, are not clearly
stated and are largely
personal opinions.
Minimal direct connections
are made to readings and/or
other course materials
(lectures, media, resources,
etc.). Connections are
largely inferred and
somewhat unclear at times.
Some direct connections are
made to readings and/or
other course materials
(lectures, media, resources,
etc.) and are clearly stated
for the most part.
Strong, direct connections
are made to readings
and/or other course
materials (lectures, media,
resources, etc.) and are
clearly stated.
Content and
Pedagogical
Knowledge
0-13 points 14-15 points 16-17 points 18-20 points /20
The case study response
displays a lack of
comprehension of the
assignment.
The case study responses
are partially addressed.
There are components of
the assignment not
addressed.
The case study response
demonstrates
comprehension of
assignment expectations,
however, is missing
responses to some of the
case study questions.
The case study response
demonstrates
comprehension of
assignment expectations
and includes the essential
components of the
assignment.
2
Case Study Rubric (continued)
Criteria Unsatisfactory-Beginning Developing Accomplished Exemplary Total
Writing
Quality
0-6 points 7 points 8 points 9-10 points /10
Responses to case study
show a below average/poor
writing style that lacks
standard English, and/or is
difficult for readers to
follow. Contains frequent
errors in grammar,
punctuation, usage, and
spelling.
Responses to case study
show an average and/or
casual writing style using
standard English that is
generally clear but contains
some errors in grammar,
punctuation, usage, and
spelling.
Responses to case study
show above average writing
style that is clear using
standard English with minor
errors in grammar,
punctuation, usage, and/or
spelling.
Responses to case study
are well written and
clearly articulated using
standard English,
characterized by elements
of a strong writing style
with correct grammar,
punctuation, usage, and
spelling.
TOTAL POINTS (sum of Criteria) /100
Source: Rubric by Denise Kreiger, Instructional Design/Technology Services, SC&I, Rutgers, 3/2014
– Source: Rubric by Denise Kreiger, Instructional Design/Technology Services, SC&I, Rutgers, 3/2014
**## MSN5550SignatureAssignment5.pdf**
MSN 5550 Health Promotion: Prevention of Disease
Case Study Module 2
Instructions: Read the following case study and answer the reflective questions. Please provide
evidence-based rationales for your answers. APA, 7th ed. must be followed.
Due: Saturday by 23:59 pm
CASE STUDY: An Older Immigrant Couple: Mr. and Mrs. Arahan
Mr. and Mrs. Arahan, an older couple in their seventies, have been living with their oldest daughter,
her husband of 15 years, and their two children, ages 12 and 14. They all live in a middle-income
neighborhood in a suburb of a metropolitan city. Mr. and Mrs. Arahan are both college educated and
worked full-time while they were in their native country. In addition, Mr. Arahan, the only offspring
of wealthy parents, inherited a substantial amount of money and real estate. Their daughter came to
the United States as a registered nurse and met her husband, a drug company representative. The
older couple moved to the United States when their daughter became a U.S. citizen and petitioned
them as immigrants. Since the couple was facing retirement, they welcomed the opportunity to come
to the United States.
The Arahans found life in the United States different from that in their home country, but their
adjustment was not as difficult because both were healthy and spoke English fluently. Most of their
time was spent taking care of their two grandchildren and the house. As the grandchildren grew older,
the older couple found that they had more spare time. The daughter and her husband advanced in
their careers and spent a great deal more time at their jobs. There were few family dinners during
the week. On weekends, the daughter, her husband, and their children socialized with their own
friends. The couple began to feel isolated and longed for a more active life.
Mr. and Mrs. Arahan began to think that perhaps they should return to the home country, where
they still had relatives and friends. However, political and economic issues would have made it
difficult for them to live there. Besides, they had become accustomed to the way of life in the United
States with all the modern conveniences and abundance of goods that were difficult to obtain in their
country. However, they also became concerned that they might not be able to tolerate the winter
months and that minor health problems might worsen as they aged. They wondered who would take
care of them if they became very frail and where they would live, knowing that their daughter had
only saved money for their grandchildren’s college education. They expressed their sentiments to
their daughter, who became very concerned about how her parents were feeling.
This older couple had been attending church on a regular basis, but had never been active in other
church-related activities. The church bulletin announced the establishment of parish nursing with
two retired registered nurses as volunteers. The couple attended the first opening of the parish clinic.
Here, they met one of the registered nurses, who had a short discussion with them about the services
offered. The registered nurse had spent a great deal of her working years as a community health
nurse. She informed Mr. and Mrs. Arahan of her availability to help them resolve any health-related
issues.
Reflective Questions
1. What strategies could be suggested for this older adult couple to enhance their quality of life?
2. What community resources can they utilize?
3. What can the daughter and her family do to address the feelings of isolation of the older couple?
4. What health promotion activities can ensure a healthy lifestyle for them?
– CASE STUDY: An Older Immigrant Couple: Mr. and Mrs. Arahan
– Reflective Questions
**## SignatureAssignmentRubric7.pdf**
1
MSN5550 Health Promotion: Prevention of Disease
Case Study Rubric
Criteria Unsatisfactory-Beginning Developing Accomplished Exemplary Total
Ideas,
Arguments,
& Analysis
0-30 points 35-39 points 40-44 points 45-50 points /50
Ideas expressed lack an
understanding of the case
study. Comments are
irrelevant, off-topic, and/or
confusing to follow.
Viewpoint, if given, is not
supported with evidence or
examples.
Ideas expressed in case
study show a minimal
understanding of the topic.
Comments are general in
nature and/or occasionally
may not be relevant.
Rehashes or summarizes
ideas with limited analysis,
original thought, and/or
supported viewpoints.
Ideas expressed in case
study are mostly substantive
and relevant to topic; some
original thought.
Demonstrates logical
thinking, reasoning, and/or
analysis for most part.
Viewpoint is supported with
evidence and/or examples.
Ideas expressed in case
study include original
thought, substantial
depth, and are relevant to
topic. Responses show
strong logical thinking,
reasoning, and analysis
with evidence and
examples. Construction of
new meaning and insights
are evident.
Connection
to Course
Materials
0-13 points 14-15 points 16-17 points 18-20 points /20
No connections are made
to readings or other course
materials (lectures, media,
resources, etc.), and/or if
made, are not clearly
stated and are largely
personal opinions.
Minimal direct connections
are made to readings and/or
other course materials
(lectures, media, resources,
etc.). Connections are
largely inferred and
somewhat unclear at times.
Some direct connections are
made to readings and/or
other course materials
(lectures, media, resources,
etc.) and are clearly stated
for the most part.
Strong, direct connections
are made to readings
and/or other course
materials (lectures, media,
resources, etc.) and are
clearly stated.
Content and
Pedagogical
Knowledge
0-13 points 14-15 points 16-17 points 18-20 points /20
The case study response
displays a lack of
comprehension of the
assignment.
The case study responses
are partially addressed.
There are components of
the assignment not
addressed.
The case study response
demonstrates
comprehension of
assignment expectations,
however, is missing
responses to some of the
case study questions.
The case study response
demonstrates
comprehension of
assignment expectations
and includes the essential
components of the
assignment.
2
Case Study Rubric (continued)
Criteria Unsatisfactory-Beginning Developing Accomplished Exemplary Total
Writing
Quality
0-6 points 7 points 8 points 9-10 points /10
Responses to case study
show a below average/poor
writing style that lacks
standard English, and/or is
difficult for readers to
follow. Contains frequent
errors in grammar,
punctuation, usage, and
spelling.
Responses to case study
show an average and/or
casual writing style using
standard English that is
generally clear but contains
some errors in grammar,
punctuation, usage, and
spelling.
Responses to case study
show above average writing
style that is clear using
standard English with minor
errors in grammar,
punctuation, usage, and/or
spelling.
Responses to case study
are well written and
clearly articulated using
standard English,
characterized by elements
of a strong writing style
with correct grammar,
punctuation, usage, and
spelling.
TOTAL POINTS (sum of Criteria) /100
Source: Rubric by Denise Kreiger, Instructional Design/Technology Services, SC&I, Rutgers, 3/2014
– Source: Rubric by Denise Kreiger, Instructional Design/Technology Services, SC&I, Rutgers, 3/2014
**## MSN5550SignatureAssignment5.pdf**
MSN 5550 Health Promotion: Prevention of Disease
Case Study Module 2
Instructions: Read the following case study and answer the reflective questions. Please provide
evidence-based rationales for your answers. APA, 7th ed. must be followed.
Due: Saturday by 23:59 pm
CASE STUDY: An Older Immigrant Couple: Mr. and Mrs. Arahan
Mr. and Mrs. Arahan, an older couple in their seventies, have been living with their oldest daughter,
her husband of 15 years, and their two children, ages 12 and 14. They all live in a middle-income
neighborhood in a suburb of a metropolitan city. Mr. and Mrs. Arahan are both college educated and
worked full-time while they were in their native country. In addition, Mr. Arahan, the only offspring
of wealthy parents, inherited a substantial amount of money and real estate. Their daughter came to
the United States as a registered nurse and met her husband, a drug company representative. The
older couple moved to the United States when their daughter became a U.S. citizen and petitioned
them as immigrants. Since the couple was facing retirement, they welcomed the opportunity to come
to the United States.
The Arahans found life in the United States different from that in their home country, but their
adjustment was not as difficult because both were healthy and spoke English fluently. Most of their
time was spent taking care of their two grandchildren and the house. As the grandchildren grew older,
the older couple found that they had more spare time. The daughter and her husband advanced in
their careers and spent a great deal more time at their jobs. There were few family dinners during
the week. On weekends, the daughter, her husband, and their children socialized with their own
friends. The couple began to feel isolated and longed for a more active life.
Mr. and Mrs. Arahan began to think that perhaps they should return to the home country, where
they still had relatives and friends. However, political and economic issues would have made it
difficult for them to live there. Besides, they had become accustomed to the way of life in the United
States with all the modern conveniences and abundance of goods that were difficult to obtain in their
country. However, they also became concerned that they might not be able to tolerate the winter
months and that minor health problems might worsen as they aged. They wondered who would take
care of them if they became very frail and where they would live, knowing that their daughter had
only saved money for their grandchildren’s college education. They expressed their sentiments to
their daughter, who became very concerned about how her parents were feeling.
This older couple had been attending church on a regular basis, but had never been active in other
church-related activities. The church bulletin announced the establishment of parish nursing with
two retired registered nurses as volunteers. The couple attended the first opening of the parish clinic.
Here, they met one of the registered nurses, who had a short discussion with them about the services
offered. The registered nurse had spent a great deal of her working years as a community health
nurse. She informed Mr. and Mrs. Arahan of her availability to help them resolve any health-related
issues.
Reflective Questions
1. What strategies could be suggested for this older adult couple to enhance their quality of life?
2. What community resources can they utilize?
3. What can the daughter and her family do to address the feelings of isolation of the older couple?
4. What health promotion activities can ensure a healthy lifestyle for them?
– CASE STUDY: An Older Immigrant Couple: Mr. and Mrs. Arahan
– Reflective Questions
**## SignatureAssignmentRubric7.pdf**
1
MSN5550 Health Promotion: Prevention of Disease
Case Study Rubric
Criteria Unsatisfactory-Beginning Developing Accomplished Exemplary Total
Ideas,
Arguments,
& Analysis
0-30 points 35-39 points 40-44 points 45-50 points /50
Ideas expressed lack an
understanding of the case
study. Comments are
irrelevant, off-topic, and/or
confusing to follow.
Viewpoint, if given, is not
supported with evidence or
examples.
Ideas expressed in case
study show a minimal
understanding of the topic.
Comments are general in
nature and/or occasionally
may not be relevant.
Rehashes or summarizes
ideas with limited analysis,
original thought, and/or
supported viewpoints.
Ideas expressed in case
study are mostly substantive
and relevant to topic; some
original thought.
Demonstrates logical
thinking, reasoning, and/or
analysis for most part.
Viewpoint is supported with
evidence and/or examples.
Ideas expressed in case
study include original
thought, substantial
depth, and are relevant to
topic. Responses show
strong logical thinking,
reasoning, and analysis
with evidence and
examples. Construction of
new meaning and insights
are evident.
Connection
to Course
Materials
0-13 points 14-15 points 16-17 points 18-20 points /20
No connections are made
to readings or other course
materials (lectures, media,
resources, etc.), and/or if
made, are not clearly
stated and are largely
personal opinions.
Minimal direct connections
are made to readings and/or
other course materials
(lectures, media, resources,
etc.). Connections are
largely inferred and
somewhat unclear at times.
Some direct connections are
made to readings and/or
other course materials
(lectures, media, resources,
etc.) and are clearly stated
for the most part.
Strong, direct connections
are made to readings
and/or other course
materials (lectures, media,
resources, etc.) and are
clearly stated.
Content and
Pedagogical
Knowledge
0-13 points 14-15 points 16-17 points 18-20 points /20
The case study response
displays a lack of
comprehension of the
assignment.
The case study responses
are partially addressed.
There are components of
the assignment not
addressed.
The case study response
demonstrates
comprehension of
assignment expectations,
however, is missing
responses to some of the
case study questions.
The case study response
demonstrates
comprehension of
assignment expectations
and includes the essential
components of the
assignment.
2
Case Study Rubric (continued)
Criteria Unsatisfactory-Beginning Developing Accomplished Exemplary Total
Writing
Quality
0-6 points 7 points 8 points 9-10 points /10
Responses to case study
show a below average/poor
writing style that lacks
standard English, and/or is
difficult for readers to
follow. Contains frequent
errors in grammar,
punctuation, usage, and
spelling.
Responses to case study
show an average and/or
casual writing style using
standard English that is
generally clear but contains
some errors in grammar,
punctuation, usage, and
spelling.
Responses to case study
show above average writing
style that is clear using
standard English with minor
errors in grammar,
punctuation, usage, and/or
spelling.
Responses to case study
are well written and
clearly articulated using
standard English,
characterized by elements
of a strong writing style
with correct grammar,
punctuation, usage, and
spelling.
TOTAL POINTS (sum of Criteria) /100
Source: Rubric by Denise Kreiger, Instructional Design/Technology Services, SC&I, Rutgers, 3/2014
– Source: Rubric by Denise Kreiger, Instructional Design/Technology Services, SC&I, Rutgers, 3/2014
**files (6)** – ## ActiveLearningTemplate_Therapeutic_Procedure_form.pdf – ## ActiveLearningTemplate_Diagnostic_Procedure_form.pdf – ## ActiveLearningTemplate_medication.pdf – ## AD_DailyClinical_CarePlan_ConceptMap_Updated1.20261.docx – ## AD_DailyClinical_CarePlan_ConceptMap_Updated…
Immediate access to the full model answer, formatted citations, and rubric breakdown.
Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →**files (6)**
– ## ActiveLearningTemplate_Therapeutic_Procedure_form.pdf
– ## ActiveLearningTemplate_Diagnostic_Procedure_form.pdf
– ## ActiveLearningTemplate_medication.pdf
– ## AD_DailyClinical_CarePlan_ConceptMap_Updated1.20261.docx
– ## AD_DailyClinical_CarePlan_ConceptMap_Updated1.20262.docx
– ## ActiveLearningTemplate_sysDis.pdf
**## ActiveLearningTemplate_Therapeutic_Procedure_form.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A13
Therapeutic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Procedure
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
01. STUDENT NAME:
02. PROCEDURE NAME:
03. REVIEW MODULE CHAPTER:
04. Description of Procedure:
05. Outcomes/Evaluation:
06. Potential Complications:
07. Client Education:
08. Indications:
09. Nursing Interventions:
10. Nursing Interventions (pre, intra, post):
**## ActiveLearningTemplate_Diagnostic_Procedure_form.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A3
Diagnostic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Procedure
Indications
Interpretation of Findings
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
ACTIVE LEARNING TEMPLATE:
01. STUDENT NAME:
02. PROCEDURE NAME:
03. REVIEW MODULE CHAPTER:
04. Description of Procedure:
05. Indications:
06. Interpretation of Findings:
07. Client Education:
08. Potential Complications:
09. Nursing Interventions:
10. Nursing Interventions (pre, intra, post):
**## ActiveLearningTemplate_medication.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A7
Medication
STUDENT NAME _____________________________________
MEDICATION __________________________________________________________________________ REVIEW MODULE CHAPTER ___________
CATEGORY CLASS ______________________________________________________________________
ACTIVE LEARNING TEMPLATE:
PURPOSE OF MEDICATION
Expected Pharmacological Action
Complications
Contraindications/Precautions
Interactions
Medication Administration
Evaluation of Medication Effectiveness
Therapeutic Use
Nursing Interventions
Client Education
01. STUDENT NAME:
02. MEDICATION:
03. REVIEW MODULE CHAPTER:
04. CATEGORY CLASS:
05. Therapeutic Use:
06. Complications:
07. Contraindications/Precautions:
08. Interactions:
09. Evaluation of Medication Effectiveness:
10. Expected Pharmacological Action:
11. Nursing Interventions:
12. Medication Administration:
13. Client Education:
**## AD_DailyClinical_CarePlan_ConceptMap_Updated1.20261.docx**
Nursing Diagnosis (3 part) (1 point)
Medical Diagnosis
Risk Factors
**AD Nursing**
**3** Nursing Interventions/Evaluation (3 points)
Rationale for Nursing Interventions (1 point)
Goal (measurable with time frame) (1 point)
Patient Education/Discharge Planning Needs (2 points)
Evaluation of Interventions Performed (2 points)
Diagnostic exams, tests, results relating to nursing diagnosis
Assessment data to support nursing diagnosis
Complications and information to report to HCP
**## AD_DailyClinical_CarePlan_ConceptMap_Updated1.20262.docx**
Nursing Diagnosis (3 part) (1 point)
Medical Diagnosis
Risk Factors
**AD Nursing**
**3** Nursing Interventions/Evaluation (3 points)
Rationale for Nursing Interventions (1 point)
Goal (measurable with time frame) (1 point)
Patient Education/Discharge Planning Needs (2 points)
Evaluation of Interventions Performed (2 points)
Diagnostic exams, tests, results relating to nursing diagnosis
Assessment data to support nursing diagnosis
Complications and information to report to HCP
**## ActiveLearningTemplate_sysDis.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A11
System Disorder
STUDENT NAME _____________________________________
DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
ASSESSMENT SAFETY
CONSIDERATIONS
PATIENT-CENTERED CARE
Alterations in
Health (Diagnosis)
Pathophysiology Related
to Client Problem
Health Promotion and
Disease Prevention
Risk Factors Expected Findings
Laboratory Tests Diagnostic Procedures
Complications
Therapeutic Procedures Interprofessional Care
Nursing Care Client EducationMedications
01. STUDENT NAME:
02. DISORDERDISEASE PROCESS:
03. REVIEW MODULE CHAPTER:
04. Pathophysiology Related to Client Problem:
05. Health Promotion and Disease Prevention:
06. Risk Factors:
07. Expected Findings:
08. Laboratory Tests:
09. Diagnostic Procedures:
10. Nursing Care:
11. Therapeutic Procedures:
12. Medications:
13. Client Education:
14. Interprofessional Care:
15. Alterations in Health:
16. Safety Considerations:
17. Complications:
**## ActiveLearningTemplate_sysDis.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A11
System Disorder
STUDENT NAME _____________________________________
DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
ASSESSMENT SAFETY
CONSIDERATIONS
PATIENT-CENTERED CARE
Alterations in
Health (Diagnosis)
Pathophysiology Related
to Client Problem
Health Promotion and
Disease Prevention
Risk Factors Expected Findings
Laboratory Tests Diagnostic Procedures
Complications
Therapeutic Procedures Interprofessional Care
Nursing Care Client EducationMedications
01. STUDENT NAME:
02. DISORDERDISEASE PROCESS:
03. REVIEW MODULE CHAPTER:
04. Pathophysiology Related to Client Problem:
05. Health Promotion and Disease Prevention:
06. Risk Factors:
07. Expected Findings:
08. Laboratory Tests:
09. Diagnostic Procedures:
10. Nursing Care:
11. Therapeutic Procedures:
12. Medications:
13. Client Education:
14. Interprofessional Care:
15. Alterations in Health:
16. Safety Considerations:
17. Complications:
**## ActiveLearningTemplate_Therapeutic_Procedure_form.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A13
Therapeutic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Procedure
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
01. STUDENT NAME:
02. PROCEDURE NAME:
03. REVIEW MODULE CHAPTER:
04. Description of Procedure:
05. Outcomes/Evaluation:
06. Potential Complications:
07. Client Education:
08. Indications:
09. Nursing Interventions:
10. Nursing Interventions (pre, intra, post):
**## ActiveLearningTemplate_Diagnostic_Procedure_form.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A3
Diagnostic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Procedure
Indications
Interpretation of Findings
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
ACTIVE LEARNING TEMPLATE:
01. STUDENT NAME:
02. PROCEDURE NAME:
03. REVIEW MODULE CHAPTER:
04. Description of Procedure:
05. Indications:
06. Interpretation of Findings:
07. Client Education:
08. Potential Complications:
09. Nursing Interventions:
10. Nursing Interventions (pre, intra, post):
**## ActiveLearningTemplate_medication.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A7
Medication
STUDENT NAME _____________________________________
MEDICATION __________________________________________________________________________ REVIEW MODULE CHAPTER ___________
CATEGORY CLASS ______________________________________________________________________
ACTIVE LEARNING TEMPLATE:
PURPOSE OF MEDICATION
Expected Pharmacological Action
Complications
Contraindications/Precautions
Interactions
Medication Administration
Evaluation of Medication Effectiveness
Therapeutic Use
Nursing Interventions
Client Education
01. STUDENT NAME:
02. MEDICATION:
03. REVIEW MODULE CHAPTER:
04. CATEGORY CLASS:
05. Therapeutic Use:
06. Complications:
07. Contraindications/Precautions:
08. Interactions:
09. Evaluation of Medication Effectiveness:
10. Expected Pharmacological Action:
11. Nursing Interventions:
12. Medication Administration:
13. Client Education:
**## AD_DailyClinical_CarePlan_ConceptMap_Updated1.20261.docx**
Nursing Diagnosis (3 part) (1 point)
Medical Diagnosis
Risk Factors
**AD Nursing**
**3** Nursing Interventions/Evaluation (3 points)
Rationale for Nursing Interventions (1 point)
Goal (measurable with time frame) (1 point)
Patient Education/Discharge Planning Needs (2 points)
Evaluation of Interventions Performed (2 points)
Diagnostic exams, tests, results relating to nursing diagnosis
Assessment data to support nursing diagnosis
Complications and information to report to HCP
**## AD_DailyClinical_CarePlan_ConceptMap_Updated1.20262.docx**
Nursing Diagnosis (3 part) (1 point)
Medical Diagnosis
Risk Factors
**AD Nursing**
**3** Nursing Interventions/Evaluation (3 points)
Rationale for Nursing Interventions (1 point)
Goal (measurable with time frame) (1 point)
Patient Education/Discharge Planning Needs (2 points)
Evaluation of Interventions Performed (2 points)
Diagnostic exams, tests, results relating to nursing diagnosis
Assessment data to support nursing diagnosis
Complications and information to report to HCP
**## ActiveLearningTemplate_sysDis.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A11
System Disorder
STUDENT NAME _____________________________________
DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
ASSESSMENT SAFETY
CONSIDERATIONS
PATIENT-CENTERED CARE
Alterations in
Health (Diagnosis)
Pathophysiology Related
to Client Problem
Health Promotion and
Disease Prevention
Risk Factors Expected Findings
Laboratory Tests Diagnostic Procedures
Complications
Therapeutic Procedures Interprofessional Care
Nursing Care Client EducationMedications
01. STUDENT NAME:
02. DISORDERDISEASE PROCESS:
03. REVIEW MODULE CHAPTER:
04. Pathophysiology Related to Client Problem:
05. Health Promotion and Disease Prevention:
06. Risk Factors:
07. Expected Findings:
08. Laboratory Tests:
09. Diagnostic Procedures:
10. Nursing Care:
11. Therapeutic Procedures:
12. Medications:
13. Client Education:
14. Interprofessional Care:
15. Alterations in Health:
16. Safety Considerations:
17. Complications:
**## ActiveLearningTemplate_Therapeutic_Procedure_form.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A13
Therapeutic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Procedure
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
01. STUDENT NAME:
02. PROCEDURE NAME:
03. REVIEW MODULE CHAPTER:
04. Description of Procedure:
05. Outcomes/Evaluation:
06. Potential Complications:
07. Client Education:
08. Indications:
09. Nursing Interventions:
10. Nursing Interventions (pre, intra, post):
**## ActiveLearningTemplate_Diagnostic_Procedure_form.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A3
Diagnostic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Procedure
Indications
Interpretation of Findings
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
ACTIVE LEARNING TEMPLATE:
01. STUDENT NAME:
02. PROCEDURE NAME:
03. REVIEW MODULE CHAPTER:
04. Description of Procedure:
05. Indications:
06. Interpretation of Findings:
07. Client Education:
08. Potential Complications:
09. Nursing Interventions:
10. Nursing Interventions (pre, intra, post):
**## ActiveLearningTemplate_medication.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A7
Medication
STUDENT NAME _____________________________________
MEDICATION __________________________________________________________________________ REVIEW MODULE CHAPTER ___________
CATEGORY CLASS ______________________________________________________________________
ACTIVE LEARNING TEMPLATE:
PURPOSE OF MEDICATION
Expected Pharmacological Action
Complications
Contraindications/Precautions
Interactions
Medication Administration
Evaluation of Medication Effectiveness
Therapeutic Use
Nursing Interventions
Client Education
01. STUDENT NAME:
02. MEDICATION:
03. REVIEW MODULE CHAPTER:
04. CATEGORY CLASS:
05. Therapeutic Use:
06. Complications:
07. Contraindications/Precautions:
08. Interactions:
09. Evaluation of Medication Effectiveness:
10. Expected Pharmacological Action:
11. Nursing Interventions:
12. Medication Administration:
13. Client Education:
**## AD_DailyClinical_CarePlan_ConceptMap_Updated1.20261.docx**
Nursing Diagnosis (3 part) (1 point)
Medical Diagnosis
Risk Factors
**AD Nursing**
**3** Nursing Interventions/Evaluation (3 points)
Rationale for Nursing Interventions (1 point)
Goal (measurable with time frame) (1 point)
Patient Education/Discharge Planning Needs (2 points)
Evaluation of Interventions Performed (2 points)
Diagnostic exams, tests, results relating to nursing diagnosis
Assessment data to support nursing diagnosis
Complications and information to report to HCP
**## AD_DailyClinical_CarePlan_ConceptMap_Updated1.20262.docx**
Nursing Diagnosis (3 part) (1 point)
Medical Diagnosis
Risk Factors
**AD Nursing**
**3** Nursing Interventions/Evaluation (3 points)
Rationale for Nursing Interventions (1 point)
Goal (measurable with time frame) (1 point)
Patient Education/Discharge Planning Needs (2 points)
Evaluation of Interventions Performed (2 points)
Diagnostic exams, tests, results relating to nursing diagnosis
Assessment data to support nursing diagnosis
Complications and information to report to HCP
**## ActiveLearningTemplate_sysDis.pdf**
ACTIVE LEARNING TEMPLATES TherapeuTic procedure A11
System Disorder
STUDENT NAME _____________________________________
DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
ASSESSMENT SAFETY
CONSIDERATIONS
PATIENT-CENTERED CARE
Alterations in
Health (Diagnosis)
Pathophysiology Related
to Client Problem
Health Promotion and
Disease Prevention
Risk Factors Expected Findings
Laboratory Tests Diagnostic Procedures
Complications
Therapeutic Procedures Interprofessional Care
Nursing Care Client EducationMedications
01. STUDENT NAME:
02. DISORDERDISEASE PROCESS:
03. REVIEW MODULE CHAPTER:
04. Pathophysiology Related to Client Problem:
05. Health Promotion and Disease Prevention:
06. Risk Factors:
07. Expected Findings:
08. Laboratory Tests:
09. Diagnostic Procedures:
10. Nursing Care:
11. Therapeutic Procedures:
12. Medications:
13. Client Education:
14. Interprofessional Care:
15. Alterations in Health:
16. Safety Considerations:
17. Complications:
– [\ \ IMG-20260402-WA0011.jpg](https://www.sweetstudy.com/files/img-20260402-wa0011-jpg "IMG-20260402-WA0011.jpg") – [\ \ IMG-20260402-WA0009.jpg](https://www.sweetstudy.com/files/img-20260402-wa0009-jpg "IMG-20260402-WA0009.jpg") – [\ \ IMG-20260402-WA0010.jpg](https://www.sweetstudy.com/fil…
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Order on TutorsGallery →– [\
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– [\
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IMG-20260402-WA0009.jpg](https://www.sweetstudy.com/files/img-20260402-wa0009-jpg "IMG-20260402-WA0009.jpg")
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– [\
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Due by end of day. Please write a 300 word reply to my classmate, her discussion post is below. APA format. NO AI. My professor is a stickler for AI. PLEASE NO AI. scholarly written, APA formatted and a minimum of 3 references (which may include the course textbook). " Hi everyone! I cannot believe …
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Have this question answered from scratch according to your specific instructions and deadline.
Order on TutorsGallery →Due by end of day. Please write a 300 word reply to my classmate, her discussion post is below. APA format. NO AI. My professor is a stickler for AI. PLEASE NO AI. scholarly written, APA formatted and a minimum of 3 references (which may include the course textbook).
"
Hi everyone! I cannot believe we are at the end of this course. My theory paper was based on the Internal Safety and Emotional Processing Theory. This theory was created to explain the relationship on how a patient’s individual sense of internal safety plays a role in how they process emotions. I defined the concept of internal safety which is how an individual processes emotions specifically how they maintain control, exude stability psychologically, and tolerate distress whenever tougher feelings arise. I defined another key concept of emotional processing which is how an individual takes in and interprets emotional experiences in a healthy way. This theory is unique because typically in trauma protocols or severe anxiety interventions, there is discussion on how external people and environments surrounding the individual effect their emotional regulation. This theory’s purpose is to show how without a level of internal safety created by the patient, those individuals are going to be more likely to participate in maladaptive coping strategies such as avoidance, which does perpetuate mental health symptoms related to psychiatric diagnoses (Hayes et al., 2012; Gross, 2015).
When coming up with the idea for this theory, I took influence from concepts from Internal Family Systems (IFS) therapy and Adult Children of Alcoholics and Dysfunctional Families (ACA) groups. IFS therapy and ACOA groups emphasize the necessity of building internal strength and safety especially when there is no opportunity to take solace from external environmental factors. IFS therapy practices “parts” work which is an evidence-based therapy where there is identification of parts that help the individual cope and strip away from “Self” (Brenner et al., 2023). ACOA group is a group therapy for individuals who have grown up in dysfunctional homes who participate in this group for community, and individuals work on healing their own inner child (ACOA). Both groups share the idea that internal safety of the individual requires healing even when removed from the external environment.
The Internal Safety and Emotional Processing Theory is something I will use in my daily practice as a future PMHNP. This theory will help me assess my patient’s level of internal safety then guide them on appropriate interventions and resources to help with their emotional processing. This theory is critical because without internal safety, patients are not as open to interventions of grounding, cognitive behavioral therapy, and fixing maladaptive coping strategies. There is importance with this theory that provides the framework to start at the patient’s roots rather than just trimming off the branches. "
Rochelle hunter edit **files (1)** – ## mental_health_policy_paper_updated.docx **## mental_health_policy_paper_updated.docx** ## Improving Access to Behavioral Health Integration Act and Its Impact on Psychiatric Mental Health Care Herzing University Course: Psychiatric Mental Healthcare As…
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**files (1)**
– ## mental_health_policy_paper_updated.docx
**## mental_health_policy_paper_updated.docx**
## Improving Access to Behavioral Health Integration Act and Its Impact on Psychiatric Mental Health Care
Herzing University
Course: Psychiatric Mental Healthcare
Assignment: Mental Health Policy Paper
Date: March 23, 2026
## Introduction
Mental health disorders represent a major public health concern in the United States. Millions of individuals experience mental health conditions each year, yet many struggle to access timely and effective treatment. Limited availability of mental health professionals, fragmented healthcare systems, and financial barriers often prevent individuals from receiving appropriate psychiatric services. One legislative effort designed to address these challenges is the Improving Access to Behavioral Health Integration Act (H.R. 5218, 118th Congress). This federal bill was introduced in the United States House of Representatives in 2023 and remains under consideration. The legislation focuses on expanding Medicare reimbursement for behavioral health integration services delivered in primary care settings. The goal of the policy is to strengthen collaborative care models that integrate mental health services into primary healthcare environments, thereby improving access to psychiatric treatment and care coordination for patients with behavioral health conditions.
## Overview of the Improving Access to Behavioral Health Integration Act
The Improving Access to Behavioral Health Integration Act (H.R. 5218) is designed to expand access to mental health care by strengthening reimbursement for behavioral health integration services within Medicare. Behavioral health integration refers to a collaborative care model in which primary care providers, behavioral health specialists, and care managers work together to coordinate mental health treatment. These models allow patients to receive mental health services directly within primary care settings while benefiting from psychiatric consultation and structured follow‑up.
Behavioral health integration has been recognized as an effective strategy for improving mental health outcomes and addressing provider shortages. Research demonstrates that collaborative care models can significantly improve treatment engagement, symptom reduction, and overall patient outcomes for individuals with depression and anxiety disorders (Fortney et al., 2021). By expanding reimbursement for collaborative care services, the legislation encourages healthcare organizations to adopt integrated care approaches that support comprehensive patient-centered treatment.
## Ethical, Legal, and Policy Considerations
From an ethical perspective, the Improving Access to Behavioral Health Integration Act supports the principle of justice, which emphasizes equitable access to healthcare services. Many individuals with mental health disorders face substantial barriers to receiving treatment, particularly those living in rural or underserved communities. Expanding collaborative care services through Medicare reimbursement allows more patients to receive mental health treatment within primary care environments, reducing disparities in access to care.
The legislation also supports the ethical principle of beneficence because it promotes improved patient outcomes through coordinated treatment. Collaborative care allows healthcare providers to address both physical and mental health conditions simultaneously. This is important because mental health disorders frequently occur alongside chronic medical conditions such as cardiovascular disease and diabetes. Integrated care models have been shown to improve both mental health outcomes and overall healthcare quality by ensuring that patients receive comprehensive and coordinated treatment (Reiss‑Brennan et al., 2021).
From a legal and policy standpoint, the bill addresses financial and structural barriers that prevent healthcare systems from implementing collaborative care models. Current reimbursement limitations often discourage healthcare organizations from investing in behavioral health integration programs. By expanding Medicare reimbursement policies, the legislation encourages healthcare systems to adopt integrated mental health care models that support long‑term patient outcomes.
## Impact on the Role of the Psychiatric Mental Health Nurse Practitioner
The Improving Access to Behavioral Health Integration Act has significant implications for the role of the Psychiatric Mental Health Nurse Practitioner (PMHNP). PMHNPs play a critical role in addressing the shortage of mental health professionals in the United States. As advanced practice nurses with specialized training in psychiatric assessment and treatment, PMHNPs are well positioned to participate in collaborative care teams within primary care environments.
Within behavioral health integration models, PMHNPs may serve as psychiatric consultants, medication management providers, or care coordinators working alongside primary care clinicians and behavioral health specialists. Their responsibilities may include conducting psychiatric assessments, prescribing psychotropic medications, monitoring treatment progress, and providing clinical guidance to interdisciplinary teams. Research indicates that advanced practice nurses significantly improve access to mental health services and contribute to improved healthcare outcomes in underserved populations (Patel et al., 2022).
## Impact on Healthcare Quality and Mental Health Outcomes
Collaborative care models supported by the Improving Access to Behavioral Health Integration Act have the potential to significantly improve healthcare quality and outcomes for individuals with psychiatric conditions. Integrated care models emphasize systematic patient monitoring, evidence‑based treatment protocols, and regular communication among healthcare providers.
Studies show that collaborative care approaches improve symptom management, increase treatment adherence, and enhance patient satisfaction. In addition, coordinated mental health care can reduce emergency department visits, hospitalizations, and untreated psychiatric conditions. By addressing mental health concerns earlier and more effectively, collaborative care models help improve long‑term patient outcomes and overall healthcare system efficiency (Fortney et al., 2021).
## Impact on Collaborative Care and Access to Treatment
One of the most significant benefits of the Improving Access to Behavioral Health Integration Act is its potential to expand collaborative care and improve access to psychiatric treatment. Many individuals experiencing mental health symptoms initially seek care from primary care providers rather than mental health specialists. Without integrated care systems, these patients may not receive appropriate psychiatric treatment due to referral delays or provider shortages.
Behavioral health integration allows mental health services to be delivered directly within primary care settings, which improves accessibility and reduces stigma associated with seeking psychiatric treatment. Collaborative care also promotes interdisciplinary communication between healthcare providers. PMHNPs, psychiatrists, psychologists, social workers, and primary care physicians can work together to develop comprehensive treatment plans and monitor patient progress.
Although implementing collaborative care requires investment in training and healthcare infrastructure, the long‑term benefits include improved treatment outcomes, increased access to care, and more efficient healthcare delivery systems.
## Conclusion
The Improving Access to Behavioral Health Integration Act (H.R. 5218) represents an important policy initiative designed to strengthen mental health care access in the United States. By expanding Medicare reimbursement for behavioral health integration services, the legislation promotes collaborative care models that improve coordination between primary care providers and mental health specialists. The bill also has important implications for Psychiatric Mental Health Nurse Practitioners, who are essential members of collaborative care teams.
From ethical, legal, and policy perspectives, the legislation supports equitable access to mental health treatment, enhances patient outcomes, and strengthens healthcare systems through integrated care delivery. Expanding collaborative care models has the potential to reduce barriers to psychiatric treatment and improve long‑term health outcomes for individuals experiencing mental health conditions.
## References
Fortney, J. C., Unützer, J., Wrenn, G., Pyne, J. M., Smith, G. R., Schoenbaum, M., & Harbin, H. (2021). A tipping point for measurement‑based care. Psychiatric Services, 72(3), 309–312. https://doi.org/10.1176/appi.ps.202000248
Patel, S. Y., Huskamp, H. A., Busch, A. B., Mehrotra, A., & Uscher‑Pines, L. (2022). Trends in outpatient mental health care delivered by nurse practitioners and physician assistants. Health Affairs, 41(6), 842–850. https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01777
Reiss‑Brennan, B., Brunisholz, K., Briot, P., Savitz, L., Cannon, W., Staheli, R., & James, B. (2021). Association of integrated team‑based care with health outcomes and cost. JAMA Network Open, 4(2), e2039330. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2778345
United States Congress. (2023). H.R. 5218 – Improving Access to Behavioral Health Integration Act. https://www.congress.gov/bill/118th-congress/house-bill/5218
**## mental_health_policy_paper_updated.docx**
## Improving Access to Behavioral Health Integration Act and Its Impact on Psychiatric Mental Health Care
Herzing University
Course: Psychiatric Mental Healthcare
Assignment: Mental Health Policy Paper
Date: March 23, 2026
## Introduction
Mental health disorders represent a major public health concern in the United States. Millions of individuals experience mental health conditions each year, yet many struggle to access timely and effective treatment. Limited availability of mental health professionals, fragmented healthcare systems, and financial barriers often prevent individuals from receiving appropriate psychiatric services. One legislative effort designed to address these challenges is the Improving Access to Behavioral Health Integration Act (H.R. 5218, 118th Congress). This federal bill was introduced in the United States House of Representatives in 2023 and remains under consideration. The legislation focuses on expanding Medicare reimbursement for behavioral health integration services delivered in primary care settings. The goal of the policy is to strengthen collaborative care models that integrate mental health services into primary healthcare environments, thereby improving access to psychiatric treatment and care coordination for patients with behavioral health conditions.
## Overview of the Improving Access to Behavioral Health Integration Act
The Improving Access to Behavioral Health Integration Act (H.R. 5218) is designed to expand access to mental health care by strengthening reimbursement for behavioral health integration services within Medicare. Behavioral health integration refers to a collaborative care model in which primary care providers, behavioral health specialists, and care managers work together to coordinate mental health treatment. These models allow patients to receive mental health services directly within primary care settings while benefiting from psychiatric consultation and structured follow‑up.
Behavioral health integration has been recognized as an effective strategy for improving mental health outcomes and addressing provider shortages. Research demonstrates that collaborative care models can significantly improve treatment engagement, symptom reduction, and overall patient outcomes for individuals with depression and anxiety disorders (Fortney et al., 2021). By expanding reimbursement for collaborative care services, the legislation encourages healthcare organizations to adopt integrated care approaches that support comprehensive patient-centered treatment.
## Ethical, Legal, and Policy Considerations
From an ethical perspective, the Improving Access to Behavioral Health Integration Act supports the principle of justice, which emphasizes equitable access to healthcare services. Many individuals with mental health disorders face substantial barriers to receiving treatment, particularly those living in rural or underserved communities. Expanding collaborative care services through Medicare reimbursement allows more patients to receive mental health treatment within primary care environments, reducing disparities in access to care.
The legislation also supports the ethical principle of beneficence because it promotes improved patient outcomes through coordinated treatment. Collaborative care allows healthcare providers to address both physical and mental health conditions simultaneously. This is important because mental health disorders frequently occur alongside chronic medical conditions such as cardiovascular disease and diabetes. Integrated care models have been shown to improve both mental health outcomes and overall healthcare quality by ensuring that patients receive comprehensive and coordinated treatment (Reiss‑Brennan et al., 2021).
From a legal and policy standpoint, the bill addresses financial and structural barriers that prevent healthcare systems from implementing collaborative care models. Current reimbursement limitations often discourage healthcare organizations from investing in behavioral health integration programs. By expanding Medicare reimbursement policies, the legislation encourages healthcare systems to adopt integrated mental health care models that support long‑term patient outcomes.
## Impact on the Role of the Psychiatric Mental Health Nurse Practitioner
The Improving Access to Behavioral Health Integration Act has significant implications for the role of the Psychiatric Mental Health Nurse Practitioner (PMHNP). PMHNPs play a critical role in addressing the shortage of mental health professionals in the United States. As advanced practice nurses with specialized training in psychiatric assessment and treatment, PMHNPs are well positioned to participate in collaborative care teams within primary care environments.
Within behavioral health integration models, PMHNPs may serve as psychiatric consultants, medication management providers, or care coordinators working alongside primary care clinicians and behavioral health specialists. Their responsibilities may include conducting psychiatric assessments, prescribing psychotropic medications, monitoring treatment progress, and providing clinical guidance to interdisciplinary teams. Research indicates that advanced practice nurses significantly improve access to mental health services and contribute to improved healthcare outcomes in underserved populations (Patel et al., 2022).
## Impact on Healthcare Quality and Mental Health Outcomes
Collaborative care models supported by the Improving Access to Behavioral Health Integration Act have the potential to significantly improve healthcare quality and outcomes for individuals with psychiatric conditions. Integrated care models emphasize systematic patient monitoring, evidence‑based treatment protocols, and regular communication among healthcare providers.
Studies show that collaborative care approaches improve symptom management, increase treatment adherence, and enhance patient satisfaction. In addition, coordinated mental health care can reduce emergency department visits, hospitalizations, and untreated psychiatric conditions. By addressing mental health concerns earlier and more effectively, collaborative care models help improve long‑term patient outcomes and overall healthcare system efficiency (Fortney et al., 2021).
## Impact on Collaborative Care and Access to Treatment
One of the most significant benefits of the Improving Access to Behavioral Health Integration Act is its potential to expand collaborative care and improve access to psychiatric treatment. Many individuals experiencing mental health symptoms initially seek care from primary care providers rather than mental health specialists. Without integrated care systems, these patients may not receive appropriate psychiatric treatment due to referral delays or provider shortages.
Behavioral health integration allows mental health services to be delivered directly within primary care settings, which improves accessibility and reduces stigma associated with seeking psychiatric treatment. Collaborative care also promotes interdisciplinary communication between healthcare providers. PMHNPs, psychiatrists, psychologists, social workers, and primary care physicians can work together to develop comprehensive treatment plans and monitor patient progress.
Although implementing collaborative care requires investment in training and healthcare infrastructure, the long‑term benefits include improved treatment outcomes, increased access to care, and more efficient healthcare delivery systems.
## Conclusion
The Improving Access to Behavioral Health Integration Act (H.R. 5218) represents an important policy initiative designed to strengthen mental health care access in the United States. By expanding Medicare reimbursement for behavioral health integration services, the legislation promotes collaborative care models that improve coordination between primary care providers and mental health specialists. The bill also has important implications for Psychiatric Mental Health Nurse Practitioners, who are essential members of collaborative care teams.
From ethical, legal, and policy perspectives, the legislation supports equitable access to mental health treatment, enhances patient outcomes, and strengthens healthcare systems through integrated care delivery. Expanding collaborative care models has the potential to reduce barriers to psychiatric treatment and improve long‑term health outcomes for individuals experiencing mental health conditions.
## References
Fortney, J. C., Unützer, J., Wrenn, G., Pyne, J. M., Smith, G. R., Schoenbaum, M., & Harbin, H. (2021). A tipping point for measurement‑based care. Psychiatric Services, 72(3), 309–312. https://doi.org/10.1176/appi.ps.202000248
Patel, S. Y., Huskamp, H. A., Busch, A. B., Mehrotra, A., & Uscher‑Pines, L. (2022). Trends in outpatient mental health care delivered by nurse practitioners and physician assistants. Health Affairs, 41(6), 842–850. https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01777
Reiss‑Brennan, B., Brunisholz, K., Briot, P., Savitz, L., Cannon, W., Staheli, R., & James, B. (2021). Association of integrated team‑based care with health outcomes and cost. JAMA Network Open, 4(2), e2039330. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2778345
United States Congress. (2023). H.R. 5218 – Improving Access to Behavioral Health Integration Act. https://www.congress.gov/bill/118th-congress/house-bill/5218
Due by end of day. Please write a 300 word reply to my classmate, her discussion post is below. APA format. NO AI. My professor is a stickler for AI. PLEASE NO AI. scholarly written, APA formatted and a minimum of 3 references (which may include the course textbook). " Reflecting on my mindset at th…
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Order on TutorsGallery →Due by end of day. Please write a 300 word reply to my classmate, her discussion post is below. APA format. NO AI. My professor is a stickler for AI. PLEASE NO AI. scholarly written, APA formatted and a minimum of 3 references (which may include the course textbook).
"
Reflecting on my mindset at the start of this course, I will admit that I viewed healthcare policy and politics as a distant concept. I felt that policy and politics were handled by people in offices that have been far removed from the bedside. Through my years at the bedside, I conditioned myself to focus only on the immediate clinical picture of the patient directly in front of me and the tasks required that shift. In my Module 1 discussion, I described a facility-level policy change regarding psychotropic medications. At that time, I saw my role strictly as a caregiver, and policy was just a set of rules that I had to follow. However, this course has challenged my idea that I can remain a passive bystander. Throughout this course, I am learning that the idea of policy and politics should not be a distant concept, as they are the very foundation that supports or limits our ability to provide safe, effective care.
A specific issue where I now see the need for my personal involvement is safe nurse-to-patient staffing ratios, which has moved to the forefront of the current healthcare crisis. In the past, I accepted being short-staffed on a shift as an expected inconvenience or a management failure. This course theory has allowed me to recognize that being short-staffed is not just a facility problem; safe staffing challenges are rooted in legislative and organizational policy. Recent research from Fernández-Sánchez et al. (2025) demonstrates a direct connection between nurse-patient ratios and the occurrence of adverse events for hospitalized patients. This information confirms what we already know: that inadequate staffing is a systemic risk to patient safety.
Mason et al. (2021) explains that nurses must act as political agents because our clinical experience provides real-time information that policy makers often lack. I will admit that idea made me uncomfortable at first. But the more I sit with it, the more I realize that I have been watching the consequences of policy decisions my entire career. I just did not call it that. I am still figuring out how deeply I want to step into the political arena, and part of me feels unprepared for it. At the same time, I cannot ignore that the nursing voice is often missing from the forums where these decisions are made. I understand that advocating for systemic changes, like staffing mandates, is not abandoning my nursing duties but rather a necessary extension of them. I realize that while patient advocacy has always been a core part of my job, the need for broader advocacy is actually well within my reach.
To move beyond the role of bystander, I think I can use my frontline experience as policy-relevant evidence. This starts with participating in my organization’s Safe Staffing Committee to ensure that patient acuity, not just census, drives our internal policies. While I recognize that this is a relatively small step in the overall scheme of things, it is a tangible foundation to build upon. By working to ensure that patient acuity, rather than just census, is the policy driver, I am applying my experience to shape the _what_ and _why_ of our practice.
Recent research by Mainey et al. (2025) stress that while regulatory documents often mandate this type of activism, they can create tension for nurses navigating systemic hurdles. This resonates with my own journey; while I am still weighing how deeply I want to dive into the political arena, I no longer believe that I am exempt from the process. I am leaving this course with a deeper understanding that the nursing voice is a necessary piece of systemic change.
**References**
Fernández-Sánchez, J. D., Andrés-Pretel, F., Ortiz-Diaz, V., Molina-Alarcón, M., & Lozano-Hernández, C. M. (2025). Relationship between the nurse–patient ratio and adverse events in conventional hospitalization units in a third‐level hospital. _Journal of Nursing Management_, _2025_(1). https://doi.org/10.1155/jonm/8885593
Mainey, L., Richardson, S., Essex, R., & Dillard-Wright, J. (2025). Nursing advocacy and activism: A critical analysis of regulatory documents. _Nursing ethics_, _32_(3), 980–993. [https://doi.org/10.1177/09697330241299525](https://doi.org/10.1177/09697330241299525)
Mason, D. J., Dickson, E. L., McLemore, M. R., Perez, G. A., Trent-Adams, S., & Underwood, L. (2021). Policy & Politics in Nursing and Health Care (8th ed.). Elsevier. [https://online.vitalsource.com/books/9780323554985](https://online.vitalsource.com/books/9780323554985)"
**files (3)** – ## physicalexamassignment.docx – ## GraduateSOAPNOTETEMPLATE.docx – ## STUFNPSOAPNoteRubric.pdf **## physicalexamassignment.docx** **Overview:** SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached …
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– ## physicalexamassignment.docx
– ## GraduateSOAPNOTETEMPLATE.docx
– ## STUFNPSOAPNoteRubric.pdf
**## physicalexamassignment.docx**
**Overview:**
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
**Instructions: (The patient is a 25 years old Female, coming for a routine physical exam)**
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
·
**S** = Subjective data: Patient’s Chief Complaint (CC).
·
**O** = Objective data: Including client behavior, physical assessment, vital signs, and meds.
·
**A** = Assessment: Diagnosis of the patient's condition. Include differential diagnosis.
·
**P** = Plan: Treatment, diagnostic testing, and follow up
**Submission Instructions:**
· Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
· Complete and submit the assignment using the appropriate template.
**Grading Rubric**
Your assignment will be graded according to the grading rubric.
**## GraduateSOAPNOTETEMPLATE.docx**
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Copyright © MVJ 2018****
****image1.png****
**## STUFNPSOAPNoteRubric.pdf**
Distinguised Excellent Fair Poor
Includes a direct quote from patient about
presenting problem
Includes a direct quote from patient and other
unrelated information
Includes information but information is NOT a
direct quote
Information is completely missing
4 Points 3 Points 2 Points 0 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity and gender) Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes the presenting problem and the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors,
Timing and Severity)
Includes the presenting problem and 7 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Includes the presenting problem and 6 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes NKA (including = Drug,
Environemental, Food, Herbal, and/or Latex
or if allergies are present (reports for each
severity of allergy AND description of
allergy)
If allergies are present, students lists type Drug,
environemtal factor, herbal, food, latex name and
includes severity of allergy OR description of
allergy
If allergies are present, students lists only the
type of allergy name Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a minimum of 3 assessments for
each body system and assesses at least 9
body systems directed to chief complaint
AND uses the words “admits” and “denies”
Includes 3 or fewer assessments for each body
system and assesses 5-8 body systems directed to
chief complaint AND uses the words “admits”
and “denies”
Includes 3 or fewer assessments for each body
system and assesses less than 5 body systems
directed to chief complaint OR student does not
use the words “admits” and “denies”
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes all 8 vital signs, (BP (with patient
position), HR, RR, temperature (with
Fahrenheit or Celsius and route of
temperature collection), weight, height, BMI
(or percentiles for pediatric population) and
pain.)
Includes 7 vital signs, (BP (with patient position),
HR, RR, temperature (with Fahrenheit or Celsius
and route of temperature collection), weight,
height, BMI (or percentiles for pediatric
population) and pain.)
Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with Fahrenheit
or Celsius and route of temperature collection),
weight, height, BMI (or percentiles for pediatric
population) and pain.)
Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a list of the labs reviewed at the
visit, values of lab results and highlights
abnormal values OR acknowledges no
labs/diagnostic tests were reviewed.
Includes a list of the labs reviewed at the visit,
values of lab results but does not highlight
abnormal values.
Includes a list of the labs reviewed at the visit but
does not include the values of lab results or
highlight abnormal values. Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for
the medication (including name, dose, route,
frequency)
Includes a list of all of the patient reported
medications and the medical diagnosis for the
medication (including 3 of the 4: name, dose,
medications route, frequency)
Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose,
route, frequency) Information is completely missing
Subjective
Objective
Medications
Labs
Review of Systems (ROS)
History of the Present Illness (HPI)
Demographics
Chief Complaint (Reason for seeking
health care)
Allergies
Vital Signs
4 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 5
screening tests
Includes an assessment of at least 4 screening
tests
Includes an assessment of at least 3 screening
tests
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis
is active or current
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
either year of diagnosis OR whether the diagnosis
is active or current
Includes each medical diagnosis but does not
include year of diagnosis or whether the
diagnosis is active or current Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes, for each surgical procedure, the
year of procedure and the indication for the
procedure
Includes, for each surgical procedure, the year of
procedure OR indication of the procedure
Includes, for each surgical procedure but not the
year of procedure or indication of the procedure Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and
cancer.
Includes an assessment of at least 3 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Includes an assessment of at least 2 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes all of the following: tobacco use,
drug use, alcohol use, marital status,
employment status, current/previous
occupation, sexual orientation, sexually
active, contraceptive use, and living
situation.
Includes 10 of the 11 following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a minimum of 4 assessments for
each body system and assesses at least 5
body systems directed to chief complaint
Includes a minimum of 3 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes a clear outline of the accurate
principal diagnosis AND lists the remaining
diagnoses addressed at the visit (in
descending priority)
Includes a clear outline of the accurate diagnoses
addressed at the visit but does not list the
diagnoses in descending order of priority
Includes an inaccurate diagnosis as the principal
diagnosis Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 differential diagnoses for
the principal diagnosis
Includes 2 differential diagnoses for the principal
diagnosis
Includes 1 differential diagnosis for the principal
diagnosis
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Diagnosis
Assessment
Plan
Family History
Screenings
Past Medical History
Differential Diagnosis
Social History
Past Surgical History
Physical Examination
Includes a detailed pharmacologic treatment
plan for each of the diagnoses listed under
“assessment”. The plan includes ALL of
the following: drug name, dose, route,
frequency, duration and cost as well as
education related to pharmacologic agent. If
the diagnosis is a chronic problem, student
includes instructions on currently prescribed
medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes 4 of the
following 7: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis is
a chronic problem, student includes instructions
on currently prescribed medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes less than 4 of
the following: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis
is a chronic problem, student includes
instructions on currently prescribed medications
as above.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no
diagnostic testing clinically required at this
time”
Includes appropriate diagnostic/lab testing 50%
of the time OR acknowledges “no diagnostic
testing clinically required at this time”
Includes appropriate diagnostic testing less than
50% of the time. Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 strategies to promote and
develop skills for managing their illness and
at least 3 self-management methods on how
to incorporate healthy behaviors into their
lives.
Includes at least 2 strategies to promote and
develop skills for managing their illness and at
least 2 self-management methods on how to
incorporate healthy behaviors into their lives.
Includes at least 1 strategies to promote and
develop skills for managing their illness and at
least 1 self-management methods on how to
incorporate healthy behaviors into their lives.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 primary prevention
strategies (related to age/condition (i.e.
immunizations, pediatric and pre-natal
milestone anticipatory guidance)) and at
least 2 secondary prevention strategies
(related to age/condition (i.e. screening))
Includes at least 2 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e.
screening))
Includes at least 1 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e.
screening))
Information is completely missing
4 Points 2 Points 1 Points 0 Points
Includes recommendation for follow up,
including time frame (i.e. x # of
days/weeks/months)
Includes recommendation for follow up, but does
not include time frame (i.e. x # of
days/weeks/months)
Does not include follow up plan
4 Points 2 Points 0 Points 0 Points
High level of APA precision Moderate level of APA precision Incorrect APA style Information is completely missing
3 Points 2 Points 1 Points 0 Points
Free of grammar and spelling errors Writing mechanics need more precision and
attention to detail
Writing mechanics need serious attention
3 Points 2 Points 0 Points 0 Points
Pharmacologic treatment plan
Follow up plan
Writing
Grammar
References
Diagnostic/Lab Testing
Anticipatory Guidance
Education
– Sheet1
**## STUFNPSOAPNoteRubric.pdf**
Distinguised Excellent Fair Poor
Includes a direct quote from patient about
presenting problem
Includes a direct quote from patient and other
unrelated information
Includes information but information is NOT a
direct quote
Information is completely missing
4 Points 3 Points 2 Points 0 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity and gender) Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes the presenting problem and the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors,
Timing and Severity)
Includes the presenting problem and 7 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Includes the presenting problem and 6 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes NKA (including = Drug,
Environemental, Food, Herbal, and/or Latex
or if allergies are present (reports for each
severity of allergy AND description of
allergy)
If allergies are present, students lists type Drug,
environemtal factor, herbal, food, latex name and
includes severity of allergy OR description of
allergy
If allergies are present, students lists only the
type of allergy name Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a minimum of 3 assessments for
each body system and assesses at least 9
body systems directed to chief complaint
AND uses the words “admits” and “denies”
Includes 3 or fewer assessments for each body
system and assesses 5-8 body systems directed to
chief complaint AND uses the words “admits”
and “denies”
Includes 3 or fewer assessments for each body
system and assesses less than 5 body systems
directed to chief complaint OR student does not
use the words “admits” and “denies”
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes all 8 vital signs, (BP (with patient
position), HR, RR, temperature (with
Fahrenheit or Celsius and route of
temperature collection), weight, height, BMI
(or percentiles for pediatric population) and
pain.)
Includes 7 vital signs, (BP (with patient position),
HR, RR, temperature (with Fahrenheit or Celsius
and route of temperature collection), weight,
height, BMI (or percentiles for pediatric
population) and pain.)
Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with Fahrenheit
or Celsius and route of temperature collection),
weight, height, BMI (or percentiles for pediatric
population) and pain.)
Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a list of the labs reviewed at the
visit, values of lab results and highlights
abnormal values OR acknowledges no
labs/diagnostic tests were reviewed.
Includes a list of the labs reviewed at the visit,
values of lab results but does not highlight
abnormal values.
Includes a list of the labs reviewed at the visit but
does not include the values of lab results or
highlight abnormal values. Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for
the medication (including name, dose, route,
frequency)
Includes a list of all of the patient reported
medications and the medical diagnosis for the
medication (including 3 of the 4: name, dose,
medications route, frequency)
Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose,
route, frequency) Information is completely missing
Subjective
Objective
Medications
Labs
Review of Systems (ROS)
History of the Present Illness (HPI)
Demographics
Chief Complaint (Reason for seeking
health care)
Allergies
Vital Signs
4 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 5
screening tests
Includes an assessment of at least 4 screening
tests
Includes an assessment of at least 3 screening
tests
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis
is active or current
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
either year of diagnosis OR whether the diagnosis
is active or current
Includes each medical diagnosis but does not
include year of diagnosis or whether the
diagnosis is active or current Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes, for each surgical procedure, the
year of procedure and the indication for the
procedure
Includes, for each surgical procedure, the year of
procedure OR indication of the procedure
Includes, for each surgical procedure but not the
year of procedure or indication of the procedure Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and
cancer.
Includes an assessment of at least 3 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Includes an assessment of at least 2 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes all of the following: tobacco use,
drug use, alcohol use, marital status,
employment status, current/previous
occupation, sexual orientation, sexually
active, contraceptive use, and living
situation.
Includes 10 of the 11 following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a minimum of 4 assessments for
each body system and assesses at least 5
body systems directed to chief complaint
Includes a minimum of 3 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes a clear outline of the accurate
principal diagnosis AND lists the remaining
diagnoses addressed at the visit (in
descending priority)
Includes a clear outline of the accurate diagnoses
addressed at the visit but does not list the
diagnoses in descending order of priority
Includes an inaccurate diagnosis as the principal
diagnosis Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 differential diagnoses for
the principal diagnosis
Includes 2 differential diagnoses for the principal
diagnosis
Includes 1 differential diagnosis for the principal
diagnosis
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Diagnosis
Assessment
Plan
Family History
Screenings
Past Medical History
Differential Diagnosis
Social History
Past Surgical History
Physical Examination
Includes a detailed pharmacologic treatment
plan for each of the diagnoses listed under
“assessment”. The plan includes ALL of
the following: drug name, dose, route,
frequency, duration and cost as well as
education related to pharmacologic agent. If
the diagnosis is a chronic problem, student
includes instructions on currently prescribed
medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes 4 of the
following 7: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis is
a chronic problem, student includes instructions
on currently prescribed medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes less than 4 of
the following: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis
is a chronic problem, student includes
instructions on currently prescribed medications
as above.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no
diagnostic testing clinically required at this
time”
Includes appropriate diagnostic/lab testing 50%
of the time OR acknowledges “no diagnostic
testing clinically required at this time”
Includes appropriate diagnostic testing less than
50% of the time. Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 strategies to promote and
develop skills for managing their illness and
at least 3 self-management methods on how
to incorporate healthy behaviors into their
lives.
Includes at least 2 strategies to promote and
develop skills for managing their illness and at
least 2 self-management methods on how to
incorporate healthy behaviors into their lives.
Includes at least 1 strategies to promote and
develop skills for managing their illness and at
least 1 self-management methods on how to
incorporate healthy behaviors into their lives.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 primary prevention
strategies (related to age/condition (i.e.
immunizations, pediatric and pre-natal
milestone anticipatory guidance)) and at
least 2 secondary prevention strategies
(related to age/condition (i.e. screening))
Includes at least 2 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e.
screening))
Includes at least 1 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e.
screening))
Information is completely missing
4 Points 2 Points 1 Points 0 Points
Includes recommendation for follow up,
including time frame (i.e. x # of
days/weeks/months)
Includes recommendation for follow up, but does
not include time frame (i.e. x # of
days/weeks/months)
Does not include follow up plan
4 Points 2 Points 0 Points 0 Points
High level of APA precision Moderate level of APA precision Incorrect APA style Information is completely missing
3 Points 2 Points 1 Points 0 Points
Free of grammar and spelling errors Writing mechanics need more precision and
attention to detail
Writing mechanics need serious attention
3 Points 2 Points 0 Points 0 Points
Pharmacologic treatment plan
Follow up plan
Writing
Grammar
References
Diagnostic/Lab Testing
Anticipatory Guidance
Education
– Sheet1
**## physicalexamassignment.docx**
**Overview:**
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
**Instructions: (The patient is a 25 years old Female, coming for a routine physical exam)**
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
·
**S** = Subjective data: Patient’s Chief Complaint (CC).
·
**O** = Objective data: Including client behavior, physical assessment, vital signs, and meds.
·
**A** = Assessment: Diagnosis of the patient's condition. Include differential diagnosis.
·
**P** = Plan: Treatment, diagnostic testing, and follow up
**Submission Instructions:**
· Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
· Complete and submit the assignment using the appropriate template.
**Grading Rubric**
Your assignment will be graded according to the grading rubric.
**## GraduateSOAPNOTETEMPLATE.docx**
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Copyright © MVJ 2018****
****image1.png****
**## STUFNPSOAPNoteRubric.pdf**
Distinguised Excellent Fair Poor
Includes a direct quote from patient about
presenting problem
Includes a direct quote from patient and other
unrelated information
Includes information but information is NOT a
direct quote
Information is completely missing
4 Points 3 Points 2 Points 0 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity and gender) Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes the presenting problem and the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors,
Timing and Severity)
Includes the presenting problem and 7 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Includes the presenting problem and 6 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes NKA (including = Drug,
Environemental, Food, Herbal, and/or Latex
or if allergies are present (reports for each
severity of allergy AND description of
allergy)
If allergies are present, students lists type Drug,
environemtal factor, herbal, food, latex name and
includes severity of allergy OR description of
allergy
If allergies are present, students lists only the
type of allergy name Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a minimum of 3 assessments for
each body system and assesses at least 9
body systems directed to chief complaint
AND uses the words “admits” and “denies”
Includes 3 or fewer assessments for each body
system and assesses 5-8 body systems directed to
chief complaint AND uses the words “admits”
and “denies”
Includes 3 or fewer assessments for each body
system and assesses less than 5 body systems
directed to chief complaint OR student does not
use the words “admits” and “denies”
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes all 8 vital signs, (BP (with patient
position), HR, RR, temperature (with
Fahrenheit or Celsius and route of
temperature collection), weight, height, BMI
(or percentiles for pediatric population) and
pain.)
Includes 7 vital signs, (BP (with patient position),
HR, RR, temperature (with Fahrenheit or Celsius
and route of temperature collection), weight,
height, BMI (or percentiles for pediatric
population) and pain.)
Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with Fahrenheit
or Celsius and route of temperature collection),
weight, height, BMI (or percentiles for pediatric
population) and pain.)
Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a list of the labs reviewed at the
visit, values of lab results and highlights
abnormal values OR acknowledges no
labs/diagnostic tests were reviewed.
Includes a list of the labs reviewed at the visit,
values of lab results but does not highlight
abnormal values.
Includes a list of the labs reviewed at the visit but
does not include the values of lab results or
highlight abnormal values. Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for
the medication (including name, dose, route,
frequency)
Includes a list of all of the patient reported
medications and the medical diagnosis for the
medication (including 3 of the 4: name, dose,
medications route, frequency)
Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose,
route, frequency) Information is completely missing
Subjective
Objective
Medications
Labs
Review of Systems (ROS)
History of the Present Illness (HPI)
Demographics
Chief Complaint (Reason for seeking
health care)
Allergies
Vital Signs
4 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 5
screening tests
Includes an assessment of at least 4 screening
tests
Includes an assessment of at least 3 screening
tests
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis
is active or current
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
either year of diagnosis OR whether the diagnosis
is active or current
Includes each medical diagnosis but does not
include year of diagnosis or whether the
diagnosis is active or current Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes, for each surgical procedure, the
year of procedure and the indication for the
procedure
Includes, for each surgical procedure, the year of
procedure OR indication of the procedure
Includes, for each surgical procedure but not the
year of procedure or indication of the procedure Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and
cancer.
Includes an assessment of at least 3 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Includes an assessment of at least 2 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes all of the following: tobacco use,
drug use, alcohol use, marital status,
employment status, current/previous
occupation, sexual orientation, sexually
active, contraceptive use, and living
situation.
Includes 10 of the 11 following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a minimum of 4 assessments for
each body system and assesses at least 5
body systems directed to chief complaint
Includes a minimum of 3 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes a clear outline of the accurate
principal diagnosis AND lists the remaining
diagnoses addressed at the visit (in
descending priority)
Includes a clear outline of the accurate diagnoses
addressed at the visit but does not list the
diagnoses in descending order of priority
Includes an inaccurate diagnosis as the principal
diagnosis Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 differential diagnoses for
the principal diagnosis
Includes 2 differential diagnoses for the principal
diagnosis
Includes 1 differential diagnosis for the principal
diagnosis
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Diagnosis
Assessment
Plan
Family History
Screenings
Past Medical History
Differential Diagnosis
Social History
Past Surgical History
Physical Examination
Includes a detailed pharmacologic treatment
plan for each of the diagnoses listed under
“assessment”. The plan includes ALL of
the following: drug name, dose, route,
frequency, duration and cost as well as
education related to pharmacologic agent. If
the diagnosis is a chronic problem, student
includes instructions on currently prescribed
medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes 4 of the
following 7: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis is
a chronic problem, student includes instructions
on currently prescribed medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes less than 4 of
the following: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis
is a chronic problem, student includes
instructions on currently prescribed medications
as above.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no
diagnostic testing clinically required at this
time”
Includes appropriate diagnostic/lab testing 50%
of the time OR acknowledges “no diagnostic
testing clinically required at this time”
Includes appropriate diagnostic testing less than
50% of the time. Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 strategies to promote and
develop skills for managing their illness and
at least 3 self-management methods on how
to incorporate healthy behaviors into their
lives.
Includes at least 2 strategies to promote and
develop skills for managing their illness and at
least 2 self-management methods on how to
incorporate healthy behaviors into their lives.
Includes at least 1 strategies to promote and
develop skills for managing their illness and at
least 1 self-management methods on how to
incorporate healthy behaviors into their lives.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 primary prevention
strategies (related to age/condition (i.e.
immunizations, pediatric and pre-natal
milestone anticipatory guidance)) and at
least 2 secondary prevention strategies
(related to age/condition (i.e. screening))
Includes at least 2 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e.
screening))
Includes at least 1 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e.
screening))
Information is completely missing
4 Points 2 Points 1 Points 0 Points
Includes recommendation for follow up,
including time frame (i.e. x # of
days/weeks/months)
Includes recommendation for follow up, but does
not include time frame (i.e. x # of
days/weeks/months)
Does not include follow up plan
4 Points 2 Points 0 Points 0 Points
High level of APA precision Moderate level of APA precision Incorrect APA style Information is completely missing
3 Points 2 Points 1 Points 0 Points
Free of grammar and spelling errors Writing mechanics need more precision and
attention to detail
Writing mechanics need serious attention
3 Points 2 Points 0 Points 0 Points
Pharmacologic treatment plan
Follow up plan
Writing
Grammar
References
Diagnostic/Lab Testing
Anticipatory Guidance
Education
– Sheet1
**## physicalexamassignment.docx**
**Overview:**
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
**Instructions: (The patient is a 25 years old Female, coming for a routine physical exam)**
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
·
**S** = Subjective data: Patient’s Chief Complaint (CC).
·
**O** = Objective data: Including client behavior, physical assessment, vital signs, and meds.
·
**A** = Assessment: Diagnosis of the patient's condition. Include differential diagnosis.
·
**P** = Plan: Treatment, diagnostic testing, and follow up
**Submission Instructions:**
· Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
· Complete and submit the assignment using the appropriate template.
**Grading Rubric**
Your assignment will be graded according to the grading rubric.
**## GraduateSOAPNOTETEMPLATE.docx**
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Copyright © MVJ 2018****
****image1.png****
**## STUFNPSOAPNoteRubric.pdf**
Distinguised Excellent Fair Poor
Includes a direct quote from patient about
presenting problem
Includes a direct quote from patient and other
unrelated information
Includes information but information is NOT a
direct quote
Information is completely missing
4 Points 3 Points 2 Points 0 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity and gender) Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes the presenting problem and the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors,
Timing and Severity)
Includes the presenting problem and 7 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Includes the presenting problem and 6 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes NKA (including = Drug,
Environemental, Food, Herbal, and/or Latex
or if allergies are present (reports for each
severity of allergy AND description of
allergy)
If allergies are present, students lists type Drug,
environemtal factor, herbal, food, latex name and
includes severity of allergy OR description of
allergy
If allergies are present, students lists only the
type of allergy name Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a minimum of 3 assessments for
each body system and assesses at least 9
body systems directed to chief complaint
AND uses the words “admits” and “denies”
Includes 3 or fewer assessments for each body
system and assesses 5-8 body systems directed to
chief complaint AND uses the words “admits”
and “denies”
Includes 3 or fewer assessments for each body
system and assesses less than 5 body systems
directed to chief complaint OR student does not
use the words “admits” and “denies”
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes all 8 vital signs, (BP (with patient
position), HR, RR, temperature (with
Fahrenheit or Celsius and route of
temperature collection), weight, height, BMI
(or percentiles for pediatric population) and
pain.)
Includes 7 vital signs, (BP (with patient position),
HR, RR, temperature (with Fahrenheit or Celsius
and route of temperature collection), weight,
height, BMI (or percentiles for pediatric
population) and pain.)
Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with Fahrenheit
or Celsius and route of temperature collection),
weight, height, BMI (or percentiles for pediatric
population) and pain.)
Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a list of the labs reviewed at the
visit, values of lab results and highlights
abnormal values OR acknowledges no
labs/diagnostic tests were reviewed.
Includes a list of the labs reviewed at the visit,
values of lab results but does not highlight
abnormal values.
Includes a list of the labs reviewed at the visit but
does not include the values of lab results or
highlight abnormal values. Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for
the medication (including name, dose, route,
frequency)
Includes a list of all of the patient reported
medications and the medical diagnosis for the
medication (including 3 of the 4: name, dose,
medications route, frequency)
Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose,
route, frequency) Information is completely missing
Subjective
Objective
Medications
Labs
Review of Systems (ROS)
History of the Present Illness (HPI)
Demographics
Chief Complaint (Reason for seeking
health care)
Allergies
Vital Signs
4 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 5
screening tests
Includes an assessment of at least 4 screening
tests
Includes an assessment of at least 3 screening
tests
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis
is active or current
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
either year of diagnosis OR whether the diagnosis
is active or current
Includes each medical diagnosis but does not
include year of diagnosis or whether the
diagnosis is active or current Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes, for each surgical procedure, the
year of procedure and the indication for the
procedure
Includes, for each surgical procedure, the year of
procedure OR indication of the procedure
Includes, for each surgical procedure but not the
year of procedure or indication of the procedure Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and
cancer.
Includes an assessment of at least 3 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Includes an assessment of at least 2 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes all of the following: tobacco use,
drug use, alcohol use, marital status,
employment status, current/previous
occupation, sexual orientation, sexually
active, contraceptive use, and living
situation.
Includes 10 of the 11 following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a minimum of 4 assessments for
each body system and assesses at least 5
body systems directed to chief complaint
Includes a minimum of 3 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes a clear outline of the accurate
principal diagnosis AND lists the remaining
diagnoses addressed at the visit (in
descending priority)
Includes a clear outline of the accurate diagnoses
addressed at the visit but does not list the
diagnoses in descending order of priority
Includes an inaccurate diagnosis as the principal
diagnosis Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 differential diagnoses for
the principal diagnosis
Includes 2 differential diagnoses for the principal
diagnosis
Includes 1 differential diagnosis for the principal
diagnosis
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Diagnosis
Assessment
Plan
Family History
Screenings
Past Medical History
Differential Diagnosis
Social History
Past Surgical History
Physical Examination
Includes a detailed pharmacologic treatment
plan for each of the diagnoses listed under
“assessment”. The plan includes ALL of
the following: drug name, dose, route,
frequency, duration and cost as well as
education related to pharmacologic agent. If
the diagnosis is a chronic problem, student
includes instructions on currently prescribed
medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes 4 of the
following 7: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis is
a chronic problem, student includes instructions
on currently prescribed medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes less than 4 of
the following: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis
is a chronic problem, student includes
instructions on currently prescribed medications
as above.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no
diagnostic testing clinically required at this
time”
Includes appropriate diagnostic/lab testing 50%
of the time OR acknowledges “no diagnostic
testing clinically required at this time”
Includes appropriate diagnostic testing less than
50% of the time. Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 strategies to promote and
develop skills for managing their illness and
at least 3 self-management methods on how
to incorporate healthy behaviors into their
lives.
Includes at least 2 strategies to promote and
develop skills for managing their illness and at
least 2 self-management methods on how to
incorporate healthy behaviors into their lives.
Includes at least 1 strategies to promote and
develop skills for managing their illness and at
least 1 self-management methods on how to
incorporate healthy behaviors into their lives.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 primary prevention
strategies (related to age/condition (i.e.
immunizations, pediatric and pre-natal
milestone anticipatory guidance)) and at
least 2 secondary prevention strategies
(related to age/condition (i.e. screening))
Includes at least 2 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e.
screening))
Includes at least 1 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e.
screening))
Information is completely missing
4 Points 2 Points 1 Points 0 Points
Includes recommendation for follow up,
including time frame (i.e. x # of
days/weeks/months)
Includes recommendation for follow up, but does
not include time frame (i.e. x # of
days/weeks/months)
Does not include follow up plan
4 Points 2 Points 0 Points 0 Points
High level of APA precision Moderate level of APA precision Incorrect APA style Information is completely missing
3 Points 2 Points 1 Points 0 Points
Free of grammar and spelling errors Writing mechanics need more precision and
attention to detail
Writing mechanics need serious attention
3 Points 2 Points 0 Points 0 Points
Pharmacologic treatment plan
Follow up plan
Writing
Grammar
References
Diagnostic/Lab Testing
Anticipatory Guidance
Education
– Sheet1
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