Guide to Clinical Documentation Essay Discussion Paper

Guide to Clinical Documentation Essay Discussion Paper

I received a 15/100 on this assignment done by 6164. The following comments were given by the instructor.

Comments

This diagnosis was not pictured in the document of skin conditions provided. 0/35 on the rubric

Comments

Incorrect skin condition. 0/50 on the rubric

 

Please redo/Fix I only get 2 attempts

 

LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause. Guide to Clinical Documentation Essay Discussion Paper

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In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

TO PREPARE

• Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
• Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
• Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
• Consider which of the conditions is most likely to be the correct diagnosis, and why.
• Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
• Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
• Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment. Guide to Clinical Documentation Essay Discussion Paper

THE LAB ASSIGNMENT

• Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
• Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.

Resources

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach(9th ed.). St. Louis, MO: Elsevier Mosby.
  • Chapter 9, “Skin, Hair, and Nails”
    This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.
• Colyar, M. R. (2015). Advanced practice nursing procedures.Philadelphia, PA: F. A. Davis.
  Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center. Guide to Clinical Documentation Essay Discussion Paper
  This section explains the procedural knowledge needed prior to performing various dermatological procedures.
• Chapter 1, “Punch BiopsyDownload Chapter 1, “Punch Biopsy”
• Chapter 2, “Skin Biopsy”Download Chapter 2, “Skin Biopsy”
• Chapter 10, “Nail Removal”Download Chapter 10, “Nail Removal”
• Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”Download Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”
• Chapter 16, “Skin Tag (Acrochordon) Removal”Download Chapter 16, “Skin Tag (Acrochordon) Removal”
• Chapter 22, “Suture Insertion”Download Chapter 22, “Suture Insertion”
• Chapter 24, “Suture Removal”Download Chapter 24, “Suture Removal”
• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
  Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
• Chapter 28, “Rashes and Skin Lesions”Download Chapter 28, “Rashes and Skin Lesions” Guide to Clinical Documentation Essay Discussion Paper
  This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.
  Note:Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.
• Sullivan, D. D. (2019). Guide to clinical documentation(3rd ed.). Philadelphia, PA: F. A. Davis.
  • Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1 and 3)
• (2021). Clinical decision supportLinks to an external site.: For professionals. Retrieved July 16, 2021, from http://www.skinsight.com/professionals
  This interactive website allows you to explore skin conditions according to age, gender, and area of the body.
• Bonifant, H., & Holloway, S. (2019). A review of the effects of ageing on skin integrity and wound healingLinks to an external site.. British Journal of Community Nursing, 24(Sup3), S28–S33. https://doi.org/10.12968/bjcn.2019.24.sup3.s28
• Document: Skin ConditionsDownload Skin Conditions(Word document)
  This document contains images of different skin conditions. You will use this information in this week’s Discussion.
• Document: Comprehensive SOAP ExemplarDownload Comprehensive SOAP Exemplar(Word document)
• Document: Comprehensive SOAP TemplateDownload Comprehensive SOAP Template(Word document) Guide to Clinical Documentation Essay Discussion Paper

RUBRIC

Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: ·  Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). ·   Use clinical terminologies to explain the physical characteristics featured in the graphic.

35 to >29.0 pts Excellent The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies. Guide to Clinical Documentation Essay Discussion Paper

29 to >23.0 pts Good The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies.

23 to >17.0 pts Fair The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies.

17 to >0 pts Poor The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.

35 pts

This criterion is linked to a Learning Outcome·   Formulate a different diagnosis of three to five possible considerations for the skin graphic.    ·   Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.

50 to >44.0 pts Excellent The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.

44 to >38.0 pts Good The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature.

38 to >32.0 pts Fair The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature.

32 to >0 pts Poor The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.

50 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. Guide to Clinical Documentation Essay Discussion Paper

5 to >4.0 pts Excellent Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts Good Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts

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This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. Guide to Clinical Documentation Essay Discussion Paper

5 to >4.0 pts Excellent Uses correct APA format with no errors.

4 to >3.0 pts Good Contains a few (1 or 2) APA format errors.

3 to >2.0 pts Fair Contains several (3 or 4) APA format errors.

2 to >0 pts Poor Contains many (≥ 5) APA format errors. Guide to Clinical Documentation Essay Discussion Paper