Episodic Visit: HEENT Focused Note
Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly learning resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will work with a patient with a HEENT condition that you examined during the last three weeks, and complete an Episodic/Focused Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. In this weeks Learning Resources, please refer to the Focused SOAP Note resources for guidance on writing Focused Notes.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To prepare:
- Use the Episodic/Focus Note Template found in the Learning Resources for this week to complete this assignment.
- Select a patient that you examined during the last three weeks that suffered from any HEENT condition. With this patient in mind, address the following in a Focused Note:
Assignment:
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently in a similar patient evaluation?
Note: Your Focused Note Assignment must be signed by Day 7 of Week 3.
By Day 7
Submit your Episodic/Focused Note Assignment.
(Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 3.)
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK3Assgn2_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit
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