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Case Study Assignment

Case Study Assignment

Guidelines with Scoring Rubric

Purpose

The purpose of this case study assignment is to

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

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

3) Demonstrate mastery of SOAP note writing.

Course Outcomes

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

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

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

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

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

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

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

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

Total Points Possible: 200 points

Preparing the Assignment

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

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

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

Introduction: briefly discuss the purpose of this paper.

Assessment: review the provided case study information.

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

Each diagnosis will include the following information:

1. ICD 10 code.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Category Points % Description
Assessment 50 25 Each diagnosis, primary, secondary and differential, includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to your patient. Pertinent lab results are interpreted within the rationale statement.

Evidence-Based Practice (EBP) 50 25 National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later (or article related to 2018 Guidelines) are used to support the primary diagnosis and develop the plan.

Every diagnosis rationale must include an in text citation to a scholarly reference. Each action step or order within all plan sections includes an in text citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included. Reference interpretation is accurate. Diagnoses plans are consistent with the guideline recommendations.

Plan: diagnostics 10 5 All ordered diagnostics tests are linked to a diagnosis and include a paraphrased EBP rationale with citation. Each diagnosis is included in the plan.

Plans are consistent with the guideline recommendations or scholarly reference.

Plan: medications 10 5 Each prescribed and OTC medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale. Diagnosis is clearly stated in the rationale statement.

Plans are consistent with the guideline recommendations or scholarly reference

Plan: education 10 5 All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes personalized detailed education on diagnoses, medications, diet, exercise and warning signs. Personalized diet and exercise recommendations are included.

Plans are consistent with the guideline recommendations or scholarly reference.

Plan: Referrals 10 5 All recommended referrals are appropriate for the patient diagnosis; each referral is linked to a specific diagnosis and includes a paraphrased EBP rationale.

Plans are consistent with the guideline recommendations or scholarly reference

Plan: Follow up 10 5 Follow up includes a specific time/date to return to PCP office. Includes EBP rationale with in text citation. Only follow up information is listed in this section. Plans are EBP and consistent with the guideline recommendations.
Medication costs 10 5 Monthly medication costs are calculated and a total cost for the month’s medication is included.

All medications including OTCs are included.

Medication cost citation is included. Summary/reflection statement is included.

SOAP note 20 10 This SOAP note is an example of a patient chart entry. SOAP note included at end of assignment before the reference page.

SOAP note includes all elements and is formatted exactly as described in the Clinical SOAP note guidelines document. Rationales are not included. Only provided information is included in the SOAP note.

 

Grammar, Syntax, APA 10 5 APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors. All referenced information is cited, “according to” is not used.
Organization 10 5 Paper is developed in a logical, meaningful, and understandable sequence using the provided assignment template

Rationale length does not exceed template directions. SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.

The paper does not exceed 20 pages.

Total  200 100 A quality assignment will meet or exceed all of the above requirements.

 

Chamberlain College of Nursing NR601

 

CCK01/19 1

 

 

Grading Rubric

Criterion Exceptional

Outstanding or highest level of performance

Exceeds

Very good or high level of performance

Meets

Satisfactory level of performance

Needs Improvement

Poor or failing level of performance

Developing

Unsatisfactory level of performance

Content

Possible Points = 180

 

 

 

 

   

 

 
Assessment 50 Points 44 Points 41 Points 20 Points 0 Points
  All three diagnostic categories are present.

 

Each diagnosis, primary, secondary and differential, includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

 

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to your patient. Pertinent all lab results are interpreted within the rationale statement.

All three diagnostic categories are present.

 

Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

 

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement.

The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to your patient.

Pertinent lab or diagnostic results are not interpreted within the rationale statement.

 

All three diagnostic categories are present.

 

Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

 

The pathophysiology statement is not present or not paraphrased,

The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to your patient.

Pertinent lab or diagnostic results are not interpreted within the rationale statement.

 

Not all three diagnostic categories are developed: a primary, secondary or differential diagnosis category is not included.

 

Any diagnosis is not consistent with the guideline recommendations or scholarly reference.

OR

Includes treatment information

OR

Includes information that does not pertain to the case study patient such as pregnancy information or gender information that does not pertain to the case study patient’s listed gender or age.

Diagnoses are not present.
Evidence-Based Practice

 

 

50 Points 44 Points 41 Points 20 Points 0 Points
  National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later, (or article related to 2018 Guidelines) are used to support the primary diagnosis and develop the plan.

 

Every diagnosis rationale must include an in text citation to a scholarly reference. Each action step or order within all plan sections includes an in text citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included. Reference interpretation is accurate.

Diagnoses plans are consistent with the guideline recommendations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later, (or article related to 2018 Guidelines), are used to support the primary diagnosis and develop the plan.

 

Every diagnosis rationale must include an in text citation to a scholarly reference.

 

One or two steps or orders within all plan sections may be missing an in text citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.

Diagnoses plans are consistent with the guideline recommendations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later, (or article related to 2018 Guidelines), are used to support the primary diagnosis and develop the plan.

 

Every diagnosis rationale does not include an in text citation to an appropriate reference as listed in the Reference Guidelines document.

OR

One or two steps or orders within all plan sections may be missing an in text citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.

Diagnoses plans are consistent with the guideline recommendations.

The American Diabetes Association Standards and Medical Care in Diabetes-2018 or later (or article related to 2018 Guidelines) is not used to support the primary diagnosis.

OR

Not every diagnosis rationale includes an in-text citation to an appropriate reference as listed in the Reference Guidelines document. Reference interpretation is not accurate, diagnosis or plan is not consistent with the guideline recommendations.

OR

Three steps or orders within any/all plan section are missing an in text citation to an appropriate reference as listed in the Reference Guidelines document.

Scholarly information includes quotations.

Diagnoses and/or plan are not consistent with the guideline recommendations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later, (or article related to 2018 Guidelines) are not used as references.

 

  10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Diagnostics All ordered diagnostics tests are linked to a diagnosis and include a paraphrased EBP rationale with citation. Each diagnosis is included in the plan.

Plans are consistent with the guideline recommendations or scholarly reference.

All ordered diagnostics tests are linked to a diagnosis listed in the assessment section and includes an EBP rationale.

Plans are consistent with the guideline recommendations or scholarly reference.

 

A diagnosis is not included within the rationale statement.

 

All ordered diagnostics tests are linked to a diagnosis listed in the assessment section.

Plans are consistent with the guideline recommendations or scholarly reference.

 

EBP rationale within text citation is missing;

OR

Rationale is a quotation.

Ordered diagnostics tests are not linked to a diagnosis listed in the assessment section

OR

Plans are not consistent with the guideline recommendations.

 

Diagnostic tests are not included
  10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Medications Each prescribed and OTC medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale. Diagnosis is clearly stated in the rationale statement.

Plans are consistent with the guideline recommendations or scholarly reference.

All prescribed and OTC medication include a paraphrased EBP rationaleThe diagnosis is not clearly listed within the rationale statement.

Plans are consistent with the guideline recommendations or scholarly reference.

Each prescribed and OTC medication is linked to a specific diagnosis. The diagnosis is clearly listed within the rationale statement. An EBP rationale is not included

OR

Rationale is a quotation.

Plans are consistent with the guideline recommendations or scholarly reference.

Prescribed medications are listed but OTC medications are not present.

OR

Not every medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale.

OR

Plans are not consistent with the guideline recommendation or scholarly references.

Prescribed and OTC medications are not included in the case study.
  10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Education All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes personalized detailed education on diagnoses, medications, diet, exercise and warning signs. Personalized diet and exercise recommendations are included.

Plans are consistent with the guideline recommendations or scholarly reference.

All education steps are linked to a diagnosis, paraphrased and include an EBP rationale.

One or 2 educational areas are not detailed or personalized to the patient.

Plans are consistent with the guideline recommendations or scholarly reference.

All education steps are linked to a diagnosis and includes an EBP rationale.

EBP rationale

is a quotation.

OR

Three (3) or more education areas do not include personalized detailed information or scholarly reference.

Plans are consistent with the guideline recommendations or scholarly reference.

Any education step is not linked to a diagnosis, not paraphrased or an EBP rational is not provided.

OR

Plans are not consistent with the guideline recommendations or scholarly reference.

 

Education section is not present.
  10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Referral All recommended referrals are appropriate for the patient diagnosis; each referral is linked to a specific diagnosis and includes a paraphrased EBP rationale.

Plans are consistent with the guideline recommendations or scholarly reference.

Some recommended referrals are appropriate for the patient diagnosis and condition, each referral is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering.

Plans are consistent with the guideline recommendations or scholarly reference.

All recommended referrals are appropriate for the patient diagnosis and condition, includes a paraphrased EBP rationale but specific diagnosis is not stated for every referral.

OR

EBP rationale

is a quotation.

Plans are consistent with the guideline recommendations or scholarly reference.

Some recommended referrals are appropriate for the patient diagnosis and condition

Does not include a paraphrased EBP rationale for referral.

OR

Plans are not consistent with the guideline recommendations.

 

Referral section is not present.
  10 Points 9 Points 8 Points 4 Points 0 Points
Plan: Follow Up Follow up includes a specific time/date to return to PCP office. Includes EBP rationale with in text citation. Only follow up information is listed in this section. Plans are EBP and consistent with the guideline recommendations. Follow up is included in the plan but a specific time/date is not included (a range is included). Includes EBP rationale with in text citation. Only follow up information is listed in this section.

Plans are EBP and consistent with the guideline recommendations.

Follow up is included in the plan but a specific time is not included. Only follow up information is listed in this section.

Plans are consistent with the guideline recommendations.

Follow up is included in the plan; recommended follow up visit time frame is not EBP. Additional information, such as future testing, education or referrals are listed.

Plans are not consistent with the guideline recommendations.

 

Follow up section not present.
  20 Points 18 Points 16 Points 8 Points 0 Points
SOAP note SOAP note included at end of assignment before reference page.

SOAP note includes all elements and is formatted exactly as described in the SOAP note guidelines document. Rationales are not included. Only provided information is included in the SOAP note.

SOAP note included at end of assignment before reference page.

 

SOAP note includes all elements as listed in the SOAP note but not exactly as formatted in guidelines document.

Rationales are not included.

Only provided information is included in the SOAP note.

SOAP note included at end of assignment before the reference page.

 

SOAP note is formatted exactly as listed in the SOAP note guidelines document but is missing provided subjective or objective information. Subjective or objective information is not consistent with the case study. Provided information is missing or additional information is added to the SOAP note

 

SOAP note included, but not located at end of assignment before the reference page.

OR

SOAP note is not formatted exactly as shown in the SOAP note guidelines document and missing provided subjective or objective information.

Rationales are included.

 

SOAP note not included in assignment.
  10 Points 9 Points 8 Points 4 Points 0 Points
Medication costs Monthly medication costs are calculated and a total cost for the month’s medication is included.

All medications including OTCs are included.

Medication cost citation is included. Summary/reflection statement is included.

Monthly medication costs are calculated and a total cost for the month’s medications is included.

All medications including OTCs are included.

Medication cost reference is not included. Summary/reflection statement is included.

Monthly medication costs are calculated. A total cost for the month is included.

All medications including OTCs are included.

Summary/reflection statement is not included.

Monthly medication costs are calculated.

Summary statement/reflection is included.

 

Monthly medication costs are not totaled.

OR

OTCs are not included in monthly medication calculations.

 

Medication costs not calculated.
Content Subtotal

_____of 180 points
Format

Possible Points = 20

         
Grammar, Syntax, APA

 

 

10 Points 9 Points 8 Points 4 Points 0 Points
  APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors. All referenced information is cited at the end of the phrase or sentence, “according to” or the reference name is not used within cited information Two to four errors in APA format, grammar, spelling, and syntax noted. All referenced information is cited at the end of the phrase or sentence, “according to” or the reference name is not used within cited information. Five to seven errors in APA format, grammar, spelling, and syntax noted.” According to” is used as part of cited information. Eight to nine errors in APA format, grammar, spelling, and syntax noted. Post contains ten or greater errors in APA format, grammar, spelling, and/or punctuation.
Organization 10 Points 9 Points 8 Points 4 Points 0 Points
  Paper is developed in a logical, meaningful, and understandable sequence using the provided assignment template

Rationale length does not exceed template directions.

 

SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.

The paper does not exceed 20 pages.

 

Assignment contains all elements but may not be written following provided assignment template

 

SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.

Each diagnosis and action step in the plan lists the step followed by the rationale. Rationale length does not exceed template directions.

The paper length does not exceed 20 pages.

 

Paper does not contain all components and/or may be missing data.

OR

SOAP note is not written in SOAP note format as outlined in the NR 601 SOAP note format document. Rationale length does not exceed template directions..

 

The paper length does not exceed 20 pages.

 

Paper is missing three or more required sections or

Diagnoses or

plans are sometimes unclear to follow and may not always be relevant to topic. Rationale length exceeds template directions.

OR

The paper exceeds 20 pages.

 

Paper is not relevant to case study patient

OR

SOAP note is not relevant to case study.

Format Subtotal _____of 20 points
Participation

Assignment is submitted by the deadline Sunday @11:59 pm MT

Assignment submitted after the due date:

Deduction of 10% per day late up to 3 days after which a zero “0” will be recorded for the assignment.

One day late: -20 points

(Monday 12:00 am –Monday 11:59 PM MT)

Two day late: -40 points

(Tuesday 12:00 am –Tuesday 11:59 PM MT)

Three days late: -60 points

(Wednesday 12:00 am –Wednesday 11:59 PM MT)

After Wednesday 11:59pm MT- grade of zero

Total Points _____of 200 points _____of 200 points

 

NR601 Week 5 Directions & Rubric_1_2019 14

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