Advanced health assessment I: Harold James Scenario
Assignment Content
It is time to practice your documentation skills by completing a SOAP Note for Harold James.
Review the Harold James Scenario.
Use the SOAP Note Template and the SOAP Note Structure Guide to develop your documentation needed to complete your SOAP Note.
The assessment and plan sections will not be graded but should be completed to ensure documentation of a complete SOAP Note. You will also use this information to complete your E&M coding for the visit. Make sure to:
- Document all relevant information using appropriate terminology.
- List the appropriate ICD-10 codes and E&M codes using the diagnoses provided.
Submit your assignment
Well done, now that you have completed your SOAP Note for Harold James, it is time for reflection. This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives.
Write a 700-word reflection providing rationale for your completed SOAP Note. Consider the interview information provided in the patient scenario to do the following within your reflection:
- List 5 open-ended questions you would ask using descriptive language familiar to the patient during the HPI exam relevant to the chief complaint, including all pertinent and positive negatives. Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint.
- Provide a minimum of 3 rationales for the physical exam components performed.
- Locate and review a current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis. Provide a brief summary of the article(s) in your reflection.
- Identify a minimum of 2 barriers to quality health care the patient can potentially experience per the information provided in the interview (e.g., cultural, linguistic, economic, previous conditions, etc.).
- As the FNP, explain how you can address these barriers to improve the quality of care the patient receives. Use a minimum of 2 peer reviewed articles to support your answers.
Cite the references used to support your assignment.
Format your citations according to APA guidelines.
Harold James Scenario
Harold James, a 72-year-old African American male, presents with left ear pain and an episode of slurred speech. He is accompanied by his daughter who expresses concern about his memory loss over the past year. She talks with him daily on the phone and has noticed he is forgetful, repeatedly asks the same question in conversations, and does not recall conversations they had earlier in the day.
A few days ago, while having a conversation in-person with her father, she witnessed him having a brief episode of slurred speech while staring at her but wasn’t “really there.” The episode lasted about 30 seconds, and Harold has been fine since. The daughter is very worried about him because he lives alone, smokes, and drives 5 miles daily to the former music store business he owned.
Harold also complains of worsening pain in his left ear, which he has experienced for the past week. He is unable to lie on it at night. Nothing seems to make his pain better. He currently rates his pain as 8/10. His daughter has noticed the opening in his left ear is swollen and some yellowish-tan drainage. She states he has a habit of using cotton swabs aggressively and has had this problem before. She knows he is not taking his meds as directed since the weekly med container she fills has days skipped. When she questions him about it, he says he tries to remember.
Harold had a right coronary artery stent placed in 2006 and a right inguinal hernia repair in 1995. His daughter recalls something about his specialists “watching some blockage in his neck” but does not think he has had any follow-up in many years. His father and paternal uncle had Alzheimer’s and CAD.
Current meds: Bystolic® 5 mg daily, lisinopril and hydrochlorothiazide 20/25 daily, Plavix® 75 mg daily, ASA 325 daily, Lipitor® 40 mg daily.
| VS | BP: 178/98 | P: 72 | R: 16 | T: 99.2 | HT: 70’’ | WT: 197 | BMI: 28.3 |
Diagnosis:
Otitis externa
TIA.
