Tag: Nursing

  • [Solved] Review the following post and provide a reply as a DNP student of at least 250 words NO AI, use references different from post from 2020-2026

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    Vladimir 8300 In my current work setting, the primary health information technology utilized is the electronic health record (EHR) system, which serves as a critical tool for documentation, communication, and clinical decision-making. EHR systems have significantly transformed healthcare delivery by…

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    Vladimir 8300

    In my current work setting, the primary health information technology utilized is the electronic health record (EHR) system, which serves as a critical tool for documentation, communication, and clinical decision-making. EHR systems have significantly transformed healthcare delivery by improving access to patient information and supporting coordinated, patient-centered care.

    One of the major advantages of EHR use is the ability to access real-time, comprehensive patient data, including medical history, laboratory results, and medication records. This accessibility enhances clinical decision-making and reduces the risk of errors. Additionally, EHR systems improve interprofessional communication by allowing healthcare providers to document and share patient information efficiently across disciplines. Clinical decision support tools embedded within EHRs, such as alerts for drug interactions and standardized care protocols, further promote patient safety and evidence-based practice (McGonigle & Mastrian, 2022). Moreover, EHRs facilitate quality improvement initiatives by enabling the collection and analysis of data for performance metrics, which supports population health management and organizational outcomes (Aguirre et al., 2023).

    Despite these benefits, there are several limitations associated with EHR systems. One of the most significant challenges is the documentation burden, which can reduce the time available for direct patient care and contribute to provider burnout. Complex system interfaces and inefficient workflows may also decrease productivity and user satisfaction. Another concern is alert fatigue, where excessive system alerts may lead clinicians to ignore or override important warnings. Additionally, issues related to data security and patient privacy remain critical, as healthcare systems are increasingly vulnerable to cyber threats (Aguirre et al., 2023).

    In conclusion, while EHR systems provide substantial benefits in improving patient safety, communication, and quality of care, it is essential to address usability challenges and optimize system design. Continued training, system refinement, and leadership support are necessary to maximize the effectiveness of health information technology in clinical practice.

    References

    Aguirre, R. R., Suárez, O., Fuentes, M., & Sánchez-González, M. A. (2023). Electronic health records and improved patient safety: A systematic review. _Healthcare Informatics Research_, 29(1), 1–10.

    McGonigle, D., & Mastrian, K. G. (2022). _Nursing informatics and the foundation of knowledge_ (5th ed.). Jones & Bartlett

  • [Solved] Review the following paragraph and provide a reply as a DNP student at least 250 words, NO AI or plagiarism use as support references different from post from 2020-2026

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    Yusmaya 8000 Interprofessional collaboration is essential to address the complexity of modern healthcare systems, particularly in managing chronic conditions and improving population health outcomes. The DNP nurse leader plays a pivotal role in fostering collaborative environments by integrating cli…

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    Yusmaya 8000

    Interprofessional collaboration is essential to address the complexity of modern healthcare systems, particularly in managing chronic conditions and improving population health outcomes. The DNP nurse leader plays a pivotal role in fostering collaborative environments by integrating clinical expertise, systems thinking, and leadership strategies to align multidisciplinary teams toward shared goals.

    A key function of the DNP-prepared nurse is to facilitate structured communication and role clarity across disciplines. Evidence demonstrates that unclear role boundaries and poor communication are major barriers to effective collaboration, often leading to inefficiencies, duplication of work, and interprofessional conflict (Dahl & Crawford, 2018). The DNP leader addresses this gap by implementing standardized communication tools such as SBAR, interdisciplinary rounds, and shared care planning. These strategies enhance coordination, reduce fragmentation, and improve patient safety outcomes.

    Additionally, the DNP nurse leader contributes to the development of organizational systems that support collaboration. Structured workflows, defined responsibilities, and consistent interaction between professionals have been shown to significantly improve team effectiveness and care delivery outcomes (Fleischmann et al., 2016). Through the application of quality improvement methodologies such as Plan-Do-Study-Act (PDSA) cycles, the DNP leader evaluates system performance and implements sustainable changes that directly impact patient and population health outcomes.

    Another critical role of the DNP nurse leader is promoting interprofessional education and capacity building. Training initiatives that enhance understanding of each profession’s role foster trust, mutual respect, and collaborative competence among team members (Reeves et al., 2020). This is particularly important in complex care environments where overlapping responsibilities can lead to role confusion. By fostering a culture of respect and recognition, the DNP leader helps reduce hierarchical barriers and improves team dynamics.

    From a population health perspective, interprofessional collaboration supports a holistic, patient-centered approach that integrates medical, psychological, and social determinants of health. This approach improves access to care, treatment adherence, and long-term outcomes, particularly in vulnerable populations.

    This discussion aligns with several DNP Essentials. Essential II (Organizational and Systems Leadership) is demonstrated through the design and implementation of collaborative care systems. Essential III (Clinical Scholarship and Analytical Methods) is reflected in the use of evidence-based strategies to improve outcomes. Essential VI (Interprofessional Collaboration) is directly applied through the promotion of teamwork, communication, and shared decision-making across disciplines.

    Regarding leadership competencies, this discussion reflects key competencies such as communication, collaboration, systems thinking, and change management. The DNP nurse leader demonstrates the ability to lead interdisciplinary teams, resolve conflict, and implement evidence-based leadership strategies to improve healthcare delivery.

    In conclusion, the DNP nurse leader is uniquely positioned to bridge gaps between disciplines, optimize team performance, and drive meaningful improvements in both patient and population health outcomes through structured, evidence-based interprofessional collaboration.

    **References**

    Dahl, B. M., & Crawford, P. (2018). Perceptions of experiences with interprofessional collaboration in public health nursing: A qualitative analysis. Journal of Interprofessional Care, 32(2), 178–184.

    Fleischmann, N., Tetzlaff, B., Werle, J., Geister, C., Scherer, M., & Weyerer, S. (2016). Interprofessional collaboration in nursing homes: A grounded theory study. BMC Family Practice, 17(1).

    Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2020). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews.

  • [Solved] Provide a reply as. dNP student of at least 250 words No AI. References different from post from 2020-2026

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    Javier 8300 The foundational health information technology in the medical facility I practice in is the popular Electronic Health Records (EHR) system called Oracle Cerner. Oracle Cerner is an electronic platform that facilitates the storage of all patient data, such as medical history, medication r…

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    Javier 8300

    The foundational health information technology in the medical facility I practice in is the popular Electronic Health Records (EHR) system called Oracle Cerner. Oracle Cerner is an electronic platform that facilitates the storage of all patient data, such as medical history, medication records, care plan, progress notes, and diagnostic findings at a single synchronized place (Annam, 2024). Practitioners are using it to record all interactions with their patients, track behavior, and cognitive changes over time, and organize care between doctors and nurses, and even among caregivers across shifts. The system also simplifies medication management by providing proper prescription tracking and administration. Moreover, the Oracle Cerner allows our team to make cognitive evaluations, track risks of falls and provide an alert about the wandering behavior that are typical aspects of dementia care as falling risks are widespread in dementia care (Augustine et al., 2025). By summarizing all this data on a single platform, which is easy to use, the Oracle Cerner ensures that no crucial patient information is missed, even as the care teams shift throughout the day.

    The benefits of adopting Oracle Cerner are immense. Firstly, it promotes continuity of care as dementia patients may be unable to communicate their history or current condition in a coherent manner, a detailed digital record can enable all types of caregivers to learn the background, triggers, and the present state of the patient in a few seconds (Augustine et al., 2025). Second, it reduces medication errors which is highly important considering that dementia patients are often prescribed several drugs; the system will automatically warn about harmful drug combinations or omissions (Annam, 2024). Third, it facilitates a more efficient tracking of behavioral habits, sleep cycles, appetite fluctuation, and cognitive deterioration as time passes to allow the doctor to fine-tune treatment strategies with more accuracy.

    Some of the issues that can be experienced with the use of Oracle Cerner is the complexity of the system adopted and the time required before it can be used successfully, particularly on older employees who might not be so techno-savvy. Moreover, the software may contain bugs that lead to interruption of the care routine, which may also result in dangerous delays. Another serious situation is the issue of data privacy; patients with dementia are even more vulnerable to it, and any breach of their privacy concerning the vulnerable mental health information of dementia patients can be harmful to both the patients and their families (Augustine et al., 2025). The cost of maintaining and updating the system is also high and may overburden the small mental healthcare facilities. Finally, the over-reliance on technology may lead to personnel overvaluing the data delivered to them by the system over their own clinical judgment, and this is a critical problem in the mental health sector, where human vision and knowledge cannot be replaced.

    Even though Oracle Cerner has drawbacks, including complexities within a system and high prices, data privacy concerns, and decreased human interaction, they can be resolved with the help of frequent staff training, enhanced cybersecurity measures, and special technical support departments. The assessment of Oracle Cerner was informed by DNP Essential III, which necessitates the use of research and evidence-based practice to advance healthcare practices (AACN, 2021). Two role-specific competencies that were accomplished while presenting the discussion were professionalism and sound knowledge of the healthcare environment. For example, professionalism was explicitly observed during the analysis, especially in establishing issues associated with using EHRs in dementia care (AACN, 2021).

    **References**

    American Association of Colleges of Nursing (AACN). (2021). The Essentials: Core Competencies for Professional Nursing Education. AACN.

    Annam, S. N. (2024). Comparative Analysis of IT Management Tools in Healthcare. _Stallion Journal for Multidisciplinary Associated Research Studies_, _3_(5), 72-86.

    Augustine, S., Lopez, M. A., Cheun, J., & Papesh, C. (2025). Automating Cardiff Model Data Capture in Emergency Departments: Ambient NLP Integration with Oracle-Cerner FHIR Systems. _SMU Data Science Review_, _9_(3), 8.

  • [Solved] Provide a reply as aDNP student of at least 250 words . Use references different from post from 2020-2026

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    pedro 8000 The collaboration between disciplines is an important factor in today's healthcare environment for better patient safety, improved quality of healthcare delivery, and improved health status of populations. Both nurses and physicians acknowledge that collaborative practice environments pro…

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    pedro 8000

    The collaboration between disciplines is an important factor in today's healthcare environment for better patient safety, improved quality of healthcare delivery, and improved health status of populations. Both nurses and physicians acknowledge that collaborative practice environments provide better communication, fewer medical errors, and are better suited for providing patient-centered care. One of the key roles for the DNP-prepared nurse leader in developing these types of collaborative environments includes building teamwork, establishing effective communication, developing evidence-based practices, and leading through systems thinking in healthcare organizations.

    The DNP Nurse Leader works in a collaborative environment with physicians, pharmacists, social workers, therapists, and other healthcare professionals to achieve improved patient and population health outcomes, utilizing coordinated care, quality improvement initiatives, and evidence-based practice. An example of an important aspect of interdisciplinary collaboration would be medication safety. The DNP nurse leader working with pharmacists has been shown to greatly decrease medication errors and improve patient outcomes. According to (Umeano, 2024) Nursing Leadership Strategies that Support Interdisciplinary Collaboration with Pharmacists have demonstrated improvements in Medication Safety, patient-centered care, and Healthcare Outcomes through Appropriate Medication Management, monitoring adverse drug events, and Improving

    Medication Reconciliation Processes. The DNP Nurse Leader will support the development of multidisciplinary meeting times, the development of medication safety protocols, and shared decision-making amongst all Healthcare Providers to Achieve Improved Patient Outcomes and decrease healthcare costs.

    Communication and digital health systems are also key elements to interprofessional collaboration within primary care and population health management. According to (Delima et al. 2025), when there is effective communication through the use of digital healthcare, it promotes collaboration amongst healthcare providers, enhances care coordination, and improves patient outcomes in primary healthcare environments. The DNP nurse leader will be able to promote the use of electronic health records, telehealth communications tools, and shared care plans to facilitate interprofessional collaboration across disciplines and within multiple healthcare environments. These approaches will contribute to improved continuity of care; decreased hospital readmission rates; and improved management of chronic disease at the population health level.

    The subject matter of this week's discussion topic has many close relationships to DNP Essentials. Through their promotion of an interdisciplinary approach and development of health care systems, by facilitating improvements in health care services and quality improvement processes, DNP nurse leaders demonstrate their application of DNP Essential II: Organizational and Systems Leadership. The DNP Nurse Leader also demonstrates the application of DNP Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice by using current research findings and evidence-based clinical practices that promote interdisciplinary team approaches to improve the effectiveness of patient care. As a result, DNP Essential VI: Interdisciplinary Collaboration for the Improvement of Patient and Population Health Outcomes is clearly applicable to the content of this week's discussion. By working collaboratively with other members of the multidisciplinary health care team, DNP nurse leaders are able to facilitate improvements in the delivery of health care and improved patient outcomes. DNP Essential VIII: Advanced Nursing Practice is evident in the DNP nurse leader's ability to implement evidence-based interventions, which will lead to improvements in health care outcomes for patients and populations.

    The leadership competencies for this week's discussions included communication, collaboration, systems thinking, and evidence-based leadership. The DNP Nurse Leader is required to be able to lead an interdisciplinary team of healthcare professionals, communicate with other healthcare providers, develop and implement quality improvement projects; and create patient centered care. This week's discussion analyzed the different strategies of interprofessional collaborations, how they can affect healthcare outcomes, and how leadership competencies (team leadership, conflict resolution, strategic planning, quality improvement) are important for creating better patient outcomes.

    Therefore, it was concluded that the DNP nurse leaders have an enormous responsibility to foster interprofessional collaboration to help enhance the health of patients/populations through leadership, communication, evidence-based practice, and system improvements. Through interprofessional collaboration there will be increased medication safety, better coordinated care, and higher quality of healthcare. Which will result in enhanced patient care, and improved operational efficiency within the healthcare system.

    References

    Delima, M., Aljaberi, M., & Dioso, R. I. (2025). Health Workers’ Perceptions of Communication and Interprofessional Collaboration in Digital Primary Healthcare: A Cross-Sectional Study. International Journal of Nursing Information. [https://doi.org/10.58418/ijni.v4i2.170](https://doi.org/10.58418/ijni.v4i2.170)

    Umeano, A. (2024). Nursing leadership strategies for fostering interprofessional collaboration with pharmacists to improve medication safety and patient-centered healthcare outcomes. GSC Biological and Pharmaceutical Sciences. [https://doi.org/10.30574/gscbps.2024.29.3.0489](https://doi.org/10.30574/gscbps.2024.29.3.0489)

  • [Solved] Politics wk 11 reply

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    Please write a 300 word reply to my classmate, her discussion post is below. APA format. NO AI. My professor is a stickler for AI. PLEASE NO AI. scholarly written, APA formatted and a minimum of 3 references (which may include the course textbook). " I am currently not in any nursing organizations. …

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    Please write a 300 word reply to my classmate, her discussion post is below. APA format. NO AI. My professor is a stickler for AI. PLEASE NO AI.  scholarly written, APA formatted and a minimum of 3 references (which may include the course textbook).

    " I am currently not in any nursing organizations. At one point, I was a member in the International Association of Forensic Nurses (IAFN) nursing organization during my time as a Sexual Assault Nurse Examiner (SANE). Unfortunately, I am not currently a part of one. I would love to join the American Psychiatric Nurses Association (APNA). Since I currently work in psych, I believe being a part of this nursing organization would be extremely beneficial. The focus of the APNA is on advancing psychiatric mental-health nursing, and that is important to me because my ultimate goal is to become a Psychiatric Mental Health Nurse Practitioner (PMHNP). I believe this organization can help me advance my career by providing continuing education opportunities and networking events. They would also provide access to scholarly journal articles, which are very helpful for staying informed in mental healthcare.

    I believe I can make a difference by using my knowledge to advocate for patients with mental health issues and support policies that improve access to mental health care. According to Okoli (2023), accessible mental health care means that access must be provided in a way that patients and families feel welcome and safe. With the knowledge I obtain from continuing education, I can help educate patients and family members, which ensures I am providing patient-centered care.  According to Perkins et al. (2024), at the core of psychiatric mental health nursing is patient safety and creating an environment that reflects that. Network opportunities are also important. I can attend conferences with other professionals who work in mental health. Speaking to them and learning from this can be very valuable in helping me care for patients. This organization can make my transition from Psych RN to PMHNP smoother, as I will be up to date on current trends and continuing education.

    **References**

    Okoli, C. (2023). Accessible Mental Health Care Is Available, Approachable, and Affordable. _Journal of the American Psychiatric Nurses Association_, _29_(4), 352–355. [https://doi.org/10.1177/10783903231180187](https://doi.org/10.1177/10783903231180187)

    Perkins, E., Blair, E. W., Allen, D. E., Teal, L. A., Marcus, P. E., & Fordmeir, J. L. (2024). Updates to American Psychiatric Nurses Association: Seclusion and restraint position statement and standards of practice. _Journal of the American Psychiatric Nurses Association_, _30_(4), 805–809. [https://doi.org/10.1177/10783903231184200](https://doi.org/10.1177/10783903231184200)"

  • [Solved] can you help by tomorrow ?

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    **files (1)** – ## Week4EthicsInstructions.docx **## Week4EthicsInstructions.docx** Instructions For this week's assignment respond to one of the following options, and include Option 1, 2, or 3 as part of your heading. **Option 1:** The first option is to name and describe in detail a key specific …

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    **files (1)**

    – ## Week4EthicsInstructions.docx

    **## Week4EthicsInstructions.docx**

    Instructions

    For this week's assignment respond to one of the following options, and include Option 1, 2, or 3 as part of your heading.

    **Option 1:** The first option is to name and describe in detail a key specific and recent healthcare technology. What are at least two key moral problems this technology creates? What are the proper moral guidelines for dealing with it in your view? Compare your approach to what a utilitarian and ethical egoist would say (each independently). Consider whether differing ethical beliefs globally might or not agree with what you say.

    **Option 2:** In the second option, name and describe in detail a key specific and recent social technology. What are at least two key moral problems this technology creates? What are the proper moral guidelines for dealing with it in your view? Compare your moral approach to what a utilitarian and social contract ethicist would say (each independently). Consider whether differing ethical beliefs globally might or not agree with what you say.

    **Option 3:** John Doe, Patient One, is in late stage of kidney disease. If he does not receive a new kidney, then he is predicted to die within a week. Doe is 45, single, and has no children. Doctors theorize that Doe damaged his kidney by not following a low-salt diet. Doe inherited one million dollars and is known for giving money to charity. Without a transplant, he will probably be forced to spend all his money searching for a kidney outside of the usual legal channels. Patient Two is Jane Doe (no relation to John). Patient Two is a mother of two children (ages 21 and 24). She is divorced and 55 years old. She developed kidney problems due to eating a high-fat and high-sugar diet. If she does not receive a kidney within one month, doctors believe she will die. Patient Three is an orphan. This orphan lives in a state facility. She was born with a genetic condition that constantly damages her kidney. The only known approach to her condition is to provide her with a kidney transplant every so often. She is 11 and has already undergone two kidney transplants. She will perish in two months if she does not receive another transplant.

    All three patients are at the same hospital. The hospital only has one kidney to give out. The orphan's birth parents were known to be of a religion that is opposed to organ donation. The other patients come from religions that do not oppose organ donation. Who should get the kidney? Why should that candidate receive it over the others? Devise a course of social action and a solution for this case by using the ethics of egoism and then utilitarianism to a key moral conflict involving health care in this case. Appraise the interests of diverse populations (in terms of ethnicity, race, religion, sexual orientation, etc.) and how they relate to the case. Consider whether differing ethical beliefs globally might or not agree with what you say.

    For all the options:

    Cite the textbook and incorporate outside sources, including citations.

    You should not be using any text you used in a discussion board or assignment for this class or any previous class.

    Consider whether differing ethical beliefs globally might or not agree with what you say.

    You will submit the following:

    · An audiovisual presentation that presents one of the options above. Be sure to give equal time to each element. Doing a PowerPoint presentation with audio recorded on the slides is preferred. Please refer to the Narrated PowerPoint Tutorial located in the Required Resources in this assignment.

    · Please provide a transcript of anything said in the recording aloud that does not appear as text on a slide. This transcript can be provided as a Word document or placed in the Notes section on the PowerPoint slides.

    · The link or a scan of the article mentioning any health technology, social technology, or case you are reporting on. If you made up the case, please indicate that in your report. If you choose to do option #3 (the case about a shortage of transplant kidneys), your article would likely be an article about the shortage of transplant organs, or a shortage of people signing up to be transplant donors, or the status of educating people about being donors, etc.

    Requirements

    · Length: 4-6 minutes narrated presentation

    · Slide length: 4-6 slides (not including title slide, conclusion slide, or references slide)

    · Title slide

    · Conclusion slide

    · References slide (minimum of 2 scholarly sources cited in APA format; not narrated)

    **## Week4EthicsInstructions.docx**

    Instructions

    For this week's assignment respond to one of the following options, and include Option 1, 2, or 3 as part of your heading.

    **Option 1:** The first option is to name and describe in detail a key specific and recent healthcare technology. What are at least two key moral problems this technology creates? What are the proper moral guidelines for dealing with it in your view? Compare your approach to what a utilitarian and ethical egoist would say (each independently). Consider whether differing ethical beliefs globally might or not agree with what you say.

    **Option 2:** In the second option, name and describe in detail a key specific and recent social technology. What are at least two key moral problems this technology creates? What are the proper moral guidelines for dealing with it in your view? Compare your moral approach to what a utilitarian and social contract ethicist would say (each independently). Consider whether differing ethical beliefs globally might or not agree with what you say.

    **Option 3:** John Doe, Patient One, is in late stage of kidney disease. If he does not receive a new kidney, then he is predicted to die within a week. Doe is 45, single, and has no children. Doctors theorize that Doe damaged his kidney by not following a low-salt diet. Doe inherited one million dollars and is known for giving money to charity. Without a transplant, he will probably be forced to spend all his money searching for a kidney outside of the usual legal channels. Patient Two is Jane Doe (no relation to John). Patient Two is a mother of two children (ages 21 and 24). She is divorced and 55 years old. She developed kidney problems due to eating a high-fat and high-sugar diet. If she does not receive a kidney within one month, doctors believe she will die. Patient Three is an orphan. This orphan lives in a state facility. She was born with a genetic condition that constantly damages her kidney. The only known approach to her condition is to provide her with a kidney transplant every so often. She is 11 and has already undergone two kidney transplants. She will perish in two months if she does not receive another transplant.

    All three patients are at the same hospital. The hospital only has one kidney to give out. The orphan's birth parents were known to be of a religion that is opposed to organ donation. The other patients come from religions that do not oppose organ donation. Who should get the kidney? Why should that candidate receive it over the others? Devise a course of social action and a solution for this case by using the ethics of egoism and then utilitarianism to a key moral conflict involving health care in this case. Appraise the interests of diverse populations (in terms of ethnicity, race, religion, sexual orientation, etc.) and how they relate to the case. Consider whether differing ethical beliefs globally might or not agree with what you say.

    For all the options:

    Cite the textbook and incorporate outside sources, including citations.

    You should not be using any text you used in a discussion board or assignment for this class or any previous class.

    Consider whether differing ethical beliefs globally might or not agree with what you say.

    You will submit the following:

    · An audiovisual presentation that presents one of the options above. Be sure to give equal time to each element. Doing a PowerPoint presentation with audio recorded on the slides is preferred. Please refer to the Narrated PowerPoint Tutorial located in the Required Resources in this assignment.

    · Please provide a transcript of anything said in the recording aloud that does not appear as text on a slide. This transcript can be provided as a Word document or placed in the Notes section on the PowerPoint slides.

    · The link or a scan of the article mentioning any health technology, social technology, or case you are reporting on. If you made up the case, please indicate that in your report. If you choose to do option #3 (the case about a shortage of transplant kidneys), your article would likely be an article about the shortage of transplant organs, or a shortage of people signing up to be transplant donors, or the status of educating people about being donors, etc.

    Requirements

    · Length: 4-6 minutes narrated presentation

    · Slide length: 4-6 slides (not including title slide, conclusion slide, or references slide)

    · Title slide

    · Conclusion slide

    · References slide (minimum of 2 scholarly sources cited in APA format; not narrated)

  • [Solved] cardiovascular

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    In-depth study guidance and analytical solution covering cardiovascular.

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  • [Solved] Nursing homework assist

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    In-depth study guidance and analytical solution covering Nursing homework assist.

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  • [Solved] Rwh 2 soap notes

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    Rwh 2 soap notes **files (1)** – ## 1SOAPNoteTemplate-Final1_12417645411.pdf **## 1SOAPNoteTemplate-Final1_12417645411.pdf** SOAP Note NU : Herzing University Name: Typhon Encounter #: Comprehensive: Focused: S: SUBJECTIVE DATA CC: The patient reported that she has been having a worse memory and f…

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    Rwh 2 soap notes

    **files (1)**

    – ## 1SOAPNoteTemplate-Final1_12417645411.pdf

    **## 1SOAPNoteTemplate-Final1_12417645411.pdf**

    SOAP Note
    NU :

    Herzing University

    Name:
    Typhon Encounter #:

    Comprehensive: Focused:

    S: SUBJECTIVE DATA
    CC: The patient reported that she has been having a worse memory and forgetting

    things, which is confirmed by her daughter.

    HPI: History: The problems with memory started about one year ago and have become

    increasingly severe.

    Location: Cognitive/memory capability.

    Time:Ongoing throughout the last year with slow development.

    Characteristics: Becoming forgetful more often, asking the same questions and

    losing things.

    Related Factors: Daughter informs that patient experiences difficulties

    remembering the recent conversations and appointments.

    Relieving Factors: No relief is of consequence.

    Treatment: No previous pharmacologic pre-visit treatment.

    Summary: A 72-year-old female was admitted with progressive memory decline

    during a 1-year time period that was associated with forgetfulness, repetitive

    questioning, and the loss of or misplaced items.

    PMH: Hypertension (was diagnosed 10 years ago), hyperlipidemia. No major surgeries

    reported.

    ALLERGIES NKDA

    MEDICATIONS Donepezil 5 mg PO daily as a memory loss intervention.

    SH Retired teacher. Lives with daughter. Denies smoking or illicit drug use.

    Occasional alcohol use. No economic obstacles reported.

    FH In late 70s, mother was diagnosed as having dementia. Father died when he was 80

    years old because of heart attack.

    HEALTH

    PROMOTION &

    MAINTENANCE

    Patient denies severe physical exercise, walks daily. Balanced diet reported.

    Vaccinations are current with influenza vaccine. Examined eyes previously last

    year.

    ROS

    (put N/A in sections

    not completed day of

    exam)

    Constitutional Denies fever, fatigue.

    Head No headaches.

    Eyes No visual changes.

    Ears, Nose, Mouth, Throat No hearing loss and throat pain.

    Neck No stiffness.

    Cardiovascular/Peripheral

    Vascular

    Denies cardiac pain or palpitations.

    Respiratory Denies dyspnea.

    Breast

    Gastrointestinal No vomit, nausea.

    SOAP Note
    NU :

    Herzing University

    Name:
    Typhon Encounter #:

    Comprehensive: Focused:

    Genitourinary N/A

    Musculoskeletal No joint pains.

    Integumentary No rashes.

    Neurological Denies forgetfulness and loss of memory.

    Psychiatric (screening tools: Ex:

    PHQ-9, MMSE, GAD-7)

    Mild cognitive impairment observed.

    Endocrine Denies being intolerant to cold or heat.

    Hematologic/Lymphatic No bruising or bleeding.

    Allergic/Immunologic NKDA.

    Other N/A

    O: OBJECTIVE DATA
    VITALS: HR:76 RR:16 BP:126/76 Temp: 98.4°F

    SpO2%: 98% Ht: 5’4’ Wt: 150 lb BMI:25.7

    Age:72 LMP: PAIN:0/10

    PHYSICAL

    EXAM

    (Pertinent data

    related to

    presenting

    problem or

    visit type. Put

    N/A in sections

    not completed

    day of exam)

    General Appearance Observed alert, cooperative, mild impairment

    of memory.

    Head Normocephalic, atraumatic.

    Eyes PERRLA.

    ENT, Mouth Oral mucosa moist.

    Neck Soft, with no lymph node.

    Cardiovascular/Peripheral Vascular Normally high rate and beat.

    Respiratory Clear bilaterally.

    Breast

    Gastrointestinal soft abdomen, non-tender.

    Genitourinary Male

    • External Exam N/A

    • Internal Exam N/A

    Genitourinary Female

    • External Exam N/A

    • Internal Exam N/A

    Musculoskeletal the gait is normal.

    Integumentary N/A

    Neurological It is alert, person and place oriented and short

    term memory is impaired.

    Psychiatric Right mood, impaired memory slightly.

    Endocrine N/A

    Hematologic/Lymphatic N/A

    SOAP Note
    NU :

    Herzing University

    Name:
    Typhon Encounter #:

    Comprehensive: Focused:

    Allergic/Immunologic N/A

    Other N/A

    A: ASSESSMENT AND DIAGNOSIS
    DIAGNOSIS ICD-10 CODES

    PRIORITIZE
    DIAGNOSIS

    1. Alzheimer's disease ICD-10: G30.9

    2.

    3.

    VISIT CODES CPT BILLING CODES CPT-9: 99213

    DIAGNOSTICS POC TESTING CPT-10: 99203

    TESTS REVIEWED Mental examination screening (MMSE

    recommended).

    P: PLAN
    ACTIONS 1.

    Diagnosis: Alzheimer's disease

    Diagnostics Order:

    Cognitive evaluation (MMSE), regular laboratory tests to exclude metabolic

    factors.

    Therapeutic:

    Donepezil 5 mg PO on a daily basis, #30 tablets, 2 refills.

    Education:

    Management of medication adherence, routine relevance, memory aid and

    caregiver assistance were discussed. Offered home safety advice such as

    medication organizers and elimination of risks.

    Consultation/Collaboration:

    Referral to the neurology department to evaluate and manage cognition.

    SOAP Note
    NU :

    Herzing University

    Name:
    Typhon Encounter #:

    Comprehensive: Focused:

    2. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    3. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    PREVENTITIVE

    (Used for

    comprehensive exams)

    Enter Guidance, Health Promotion, and/or Disease Prevention for

    patient, family, and/or caregiver.

    FOLLOW UP Repeat visit after 3 months or earlier in case of worsening of symptoms.

    **## 1SOAPNoteTemplate-Final1_12417645411.pdf**

    SOAP Note
    NU :

    Herzing University

    Name:
    Typhon Encounter #:

    Comprehensive: Focused:

    S: SUBJECTIVE DATA
    CC: The patient reported that she has been having a worse memory and forgetting

    things, which is confirmed by her daughter.

    HPI: History: The problems with memory started about one year ago and have become

    increasingly severe.

    Location: Cognitive/memory capability.

    Time:Ongoing throughout the last year with slow development.

    Characteristics: Becoming forgetful more often, asking the same questions and

    losing things.

    Related Factors: Daughter informs that patient experiences difficulties

    remembering the recent conversations and appointments.

    Relieving Factors: No relief is of consequence.

    Treatment: No previous pharmacologic pre-visit treatment.

    Summary: A 72-year-old female was admitted with progressive memory decline

    during a 1-year time period that was associated with forgetfulness, repetitive

    questioning, and the loss of or misplaced items.

    PMH: Hypertension (was diagnosed 10 years ago), hyperlipidemia. No major surgeries

    reported.

    ALLERGIES NKDA

    MEDICATIONS Donepezil 5 mg PO daily as a memory loss intervention.

    SH Retired teacher. Lives with daughter. Denies smoking or illicit drug use.

    Occasional alcohol use. No economic obstacles reported.

    FH In late 70s, mother was diagnosed as having dementia. Father died when he was 80

    years old because of heart attack.

    HEALTH

    PROMOTION &

    MAINTENANCE

    Patient denies severe physical exercise, walks daily. Balanced diet reported.

    Vaccinations are current with influenza vaccine. Examined eyes previously last

    year.

    ROS

    (put N/A in sections

    not completed day of

    exam)

    Constitutional Denies fever, fatigue.

    Head No headaches.

    Eyes No visual changes.

    Ears, Nose, Mouth, Throat No hearing loss and throat pain.

    Neck No stiffness.

    Cardiovascular/Peripheral

    Vascular

    Denies cardiac pain or palpitations.

    Respiratory Denies dyspnea.

    Breast

    Gastrointestinal No vomit, nausea.

    SOAP Note
    NU :

    Herzing University

    Name:
    Typhon Encounter #:

    Comprehensive: Focused:

    Genitourinary N/A

    Musculoskeletal No joint pains.

    Integumentary No rashes.

    Neurological Denies forgetfulness and loss of memory.

    Psychiatric (screening tools: Ex:

    PHQ-9, MMSE, GAD-7)

    Mild cognitive impairment observed.

    Endocrine Denies being intolerant to cold or heat.

    Hematologic/Lymphatic No bruising or bleeding.

    Allergic/Immunologic NKDA.

    Other N/A

    O: OBJECTIVE DATA
    VITALS: HR:76 RR:16 BP:126/76 Temp: 98.4°F

    SpO2%: 98% Ht: 5’4’ Wt: 150 lb BMI:25.7

    Age:72 LMP: PAIN:0/10

    PHYSICAL

    EXAM

    (Pertinent data

    related to

    presenting

    problem or

    visit type. Put

    N/A in sections

    not completed

    day of exam)

    General Appearance Observed alert, cooperative, mild impairment

    of memory.

    Head Normocephalic, atraumatic.

    Eyes PERRLA.

    ENT, Mouth Oral mucosa moist.

    Neck Soft, with no lymph node.

    Cardiovascular/Peripheral Vascular Normally high rate and beat.

    Respiratory Clear bilaterally.

    Breast

    Gastrointestinal soft abdomen, non-tender.

    Genitourinary Male

    • External Exam N/A

    • Internal Exam N/A

    Genitourinary Female

    • External Exam N/A

    • Internal Exam N/A

    Musculoskeletal the gait is normal.

    Integumentary N/A

    Neurological It is alert, person and place oriented and short

    term memory is impaired.

    Psychiatric Right mood, impaired memory slightly.

    Endocrine N/A

    Hematologic/Lymphatic N/A

    SOAP Note
    NU :

    Herzing University

    Name:
    Typhon Encounter #:

    Comprehensive: Focused:

    Allergic/Immunologic N/A

    Other N/A

    A: ASSESSMENT AND DIAGNOSIS
    DIAGNOSIS ICD-10 CODES

    PRIORITIZE
    DIAGNOSIS

    1. Alzheimer's disease ICD-10: G30.9

    2.

    3.

    VISIT CODES CPT BILLING CODES CPT-9: 99213

    DIAGNOSTICS POC TESTING CPT-10: 99203

    TESTS REVIEWED Mental examination screening (MMSE

    recommended).

    P: PLAN
    ACTIONS 1.

    Diagnosis: Alzheimer's disease

    Diagnostics Order:

    Cognitive evaluation (MMSE), regular laboratory tests to exclude metabolic

    factors.

    Therapeutic:

    Donepezil 5 mg PO on a daily basis, #30 tablets, 2 refills.

    Education:

    Management of medication adherence, routine relevance, memory aid and

    caregiver assistance were discussed. Offered home safety advice such as

    medication organizers and elimination of risks.

    Consultation/Collaboration:

    Referral to the neurology department to evaluate and manage cognition.

    SOAP Note
    NU :

    Herzing University

    Name:
    Typhon Encounter #:

    Comprehensive: Focused:

    2. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    3. Diagnosis:

    Diagnostics Order:

    Therapeutic:

    Education:

    Consultation/Collaboration:

    PREVENTITIVE

    (Used for

    comprehensive exams)

    Enter Guidance, Health Promotion, and/or Disease Prevention for

    patient, family, and/or caregiver.

    FOLLOW UP Repeat visit after 3 months or earlier in case of worsening of symptoms.

  • [Solved] Nursing Assignment3_440

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    ## **Collaboration for Improving Outcomes – Discharge Plan** ### **Instructions** The purpose of this is to gain an understanding on what goes into a discharge plan. For using the case study, you will use a discharge plan for a patient using the attached [**Discharge Plan template document**](https:…

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    Assignment Prompt & Instructions

    ## **Collaboration for Improving Outcomes – Discharge Plan**

    ### **Instructions**

    The purpose of this is to gain an understanding on what goes into a discharge plan. For using the case study, you will use a discharge plan for a patient using the attached [**Discharge Plan template document**](https://learn.americansentinel.edu/pluginfile.php/1203183/mod_assign/intro/BSN%20440%20Discharge%20Plan%20Template.docx) **(See attachment)**. You are to use all sections of the discharge plan:  assessment, diagnosis/plan, education needs, financial worksheet, and the reflection and conclusion. Be as detailed as possible.