Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from your current clinical experience.
2. The patient encounter you select should be one of the more complex patient cases that you have experienced with your current clinical patient population. Given that you are to select complex cases, this assignment may not be completed for a ‘general health, well child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your ‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page (Page 1): Follow APA guidelines for running head on page 1, and include Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective (Start of Page 2): Follow APA guidelines for running head on page 2 and subsequent pages.
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
Medications: Names, dosages, and routes of administration.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.