What details did the patient provide regarding her personal and medical history?
Assignment: Gynecologic Health Paper
Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :
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 for this patient , as well as a rationale for this treatment and management plan. What details did the patient provide regarding her personal and medical history?
Very Important: Reflection notes: What would you do differently in a similar patient evaluation?
Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)
Chapter 7, “Care of the Woman with Reproductive Health Problems”
“Care of the Woman with Dysmenorrhea” (pp. 366–368)
“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418)
Assignment: Gynecologic Health
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes. What details did the patient provide regarding her personal and medical history?
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. What details did the patient provide regarding her personal and medical history?
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. What details did the patient provide regarding her personal and medical history?
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. What details did the patient provide regarding her personal and medical history?