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NU 675 Unit 14 Clinical: SOAP Note
NU 675 Unit 14 Clinical SOAP Note
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Reflective Journal Instructions
You will create 7 entries for your Reflective Journal about a patient encounter. In the 7th entry, you will review the previous 6 entries and evaluate your progress in reflective practice over the course of the term. Each journal should be a minimum of 250 words.
The purpose of this reflective journal is self-reflection regarding the role in the process of self-reflection as a PMHNP provider. Through reflective practice, the student will evaluate their own emotional health and recognize one’s own feelings as well as one’s ability to monitor and manage those feelings. The point of the exercise is to learn yourself, your triggers, the types of cases you end up getting overly involved with, and those you’d rather refer to someone else. The idea is to be able to personally reflect on your behaviors/thoughts/decisions and how those impact you in the role of PMHNP.
Address the following items:
- This is the last journal entry, please reflect on the previous 6 entries and evaluate your claims in a reflective practice over the course of the term.
- Use the appropriate APA formatting with a minimum of 2 references to support your work.
NU 675 Unit 14 Clinical: SOAP Note Grading Rubric
Performance Category | 100% or highest level of performance
100% 16 points |
Very good or high level of performance
88% 14 points |
Acceptable level of performance
81% 13 points |
Inadequate demonstration of expectations
68% 11 points |
Deficient level of performance
56% 9 points
|
Failing level
of performance 55% or less 0 points |
Total Points Possible= 50 | 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points |
Scholarliness
Demonstrates achievement of scholarly inquiry for professional and academic topics. |
Presentation of information was exceptional and included all of the following elements:
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Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three or more of the following elements
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16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points | |
Application of Course Knowledge
Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations |
Presentation of information was exceptional and included all of the following elements:
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Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in the all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three of the following elements
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10 Points | 9 Points | 6 Points | 0 Points | |||
Interactive Dialogue
Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic. |
Demonstrated all of the following:
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Demonstrated 3 of the following:
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Demonstrated 2 of the following:
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Demonstrated 1 or less of the following:
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8 Points | 7 Points | 6 Points | 5 Points | 4 Points | 0 Points | |
Grammar, Syntax, APA
Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error. |
The following was present:
AND
AND
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
|
The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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0 Points Deducted | 5 Points Lost | |||||
Participation
Requirements |
Demonstrated the following:
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Failed to demonstrate the following:
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0 Points Lost | 5 Points Lost | |||||
Due Date Requirements | Demonstrated all of the following:
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |
Demonstrates one or less of the following.
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |