Soap Note 1 Acute or Chronic Conditions (10 Points)

Iron Deficiency Anemia

Must use the sample template for your soap note, keep this template for when you start clinicals.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get grade of 0 (zero). No exceptions 

Follow the MRU Soap Note Rubric as a guide

Use APA format and must include minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 25% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated.

Please see College Handbook with reference to Academic Misconduct Statement.

The use of tempates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient. 

MRU MSN5600L SOAP NOTE Template 2021-1.docx  September 4 2023, 10:25 AM MRU Soap Note Rubric 2021-1.docx  

Purpose: Analyze and apply critical thinking skills in the psychopathology of mental health patients and provide treatment and health promotion while applying evidence-based research.

Scenario:

Kel is a 42-year-old certified public accountant (CPA) who dreams each year that she will board a cruise ship the day after Tax Day and go somewhere, anywhere, except Portsmouth, Virginia. Each year the dream, like the ocean, ebbs and flows, but this year she is not even going to think about such a “ridiculous idea.” In fact, she does not even have the energy to dream; getting out of bed and preparing to go to work is simply too labor intensive. 

Each evening Kel retires to bed with a lack of energy to complete her normal tasks such as readying her clothes for work and making a lunch. She lacks the energy to shop in the evening; consequently, she eats mostly crackers and canned soup. She is not hungry, and her scale reflects this. She has lost 15 pounds over the last 2 months. She does not attend to her makeup or clothes; she finds both too taxing. The clothes she selects are drab and not ironed. At work she makes no effort to talk with her co-workers and does not initiate new contacts with clients. The normal work of filing taxes and writing reports, which she used to enjoy, are overwhelming, and she feels too disorganized to complete them. Telephone calls and e-mail messages from friends are ignored. Attendance at work is spotty.

Sue, her sister, becomes alarmed with Kel’s unanswered telephone calls and e-mails. Worried, she decides to visit her sister at home. She finds the apartment unclean and in disarray. Kel is unkempt, disheveled, and looks sad. Her voice is monotone and flat. Kel tells Sue that she feels “sad and hopeless. Nothing is ever going to change. I am a bad person and I can’t even do my work right. Although I sleep for many hours, I am still tired all the time.” Sue is alarmed at the changes in her sister and arranges for Kel to visit a health care worker at the medical clinic.

Questions:

Remember to answer these questions from your textbooks and NP guidelines. At all times, explain your answers. 

Describe the presenting problems.

Generate a primary and differential diagnosis using the DSM5 and ICD 10 codes.

Formulate and prioritize a treatment plan. 

Identify and discuss appropriate screening instruments for a patient who has suicidal ideation.

Respond to what he wrote, be argumentative with the answers, and polite. References, and at least 2 paragraphs.

· Suggest a way to advocate for the profession.

· Share resources with those who are in your state.

Licensure and Certification in Georgia

            In Georgia, Advanced Practice Nurse Practitioners (APRNs) are governed and receive their practice authorization from the Georgia Board of Nursing. The Georgia Board of Nursing recognizes the use of the term “APRN” to cover a range of titles, which include Certified Nurse Midwives (CNM), Certified Nurse Practitioners (NP), Certified Registered Nurse Anesthetists (CRNA), Clinical Nurse Specialists/Psych-Mental Health (CNS-PMH) or Clinical Nurse Specialist (CNS). Also, in Georgia, an applicant must possess a valid registered nurse license before applying for an APRN license. According to Georgia Board of Nursing (2021), the applicant must meet the initial requirements for an APRN application, which include a completed Board application with required fee official transcript which verifies graduation with a master's or higher degree in nursing for the respective nurse practitioner specialty or a graduate level post-masters certificate in an advanced practice registered nurse practitioner specialty and evidence of advanced pharmacology within the curriculum or as a separate course, advanced physical assessment, and pathophysiology and certification of current national certification from the respective Board-recognized certifying organization. In addition, the applicant must show documentation that shows four years immediately preceding the date of current application that shows five hundred hours of practice as an APRN or graduation from a nursing education program or graduate level post-master certificate in an advanced practice registered nurse practitioner specialty or completion of Georgia Board-approved advanced practice registered nurse reentry/refresher program (Georgia Board of Nursing, 2021).

            In the state of Georgia, APRNs practice under a restricted regulatory structure. American Association of Nurse Practitioners (2022) noted that Georgia restricts patient access to nurse practitioner care and requires physician delegation/supervision for practice. Also, unlike other states, Georgia has two types of nurse protocol agreements. If the APRN is practicing under O.C.G.A. § 43-34-23, the APRN would evaluate the patient, formulate a diagnosis, determine the course of treatment, and they would call in the prescription to the pharmacy under their collaborating physician's name, just like a nurse or medical assistant would. This type of nurse protocol does not require approval from the medical board (American Association of Nurse Practitioners, 2022).  However, if the APRN practices under O.C.G.A. § 43-34-25, the APRN signs her prescriptions. This type of agreement must be submitted to the Board of Medical Examiners within 30 days of being signed (along with a fee of $150). APRNs must note that if they are to prescribe controlled substances, they must possess their own DEA number, and they are unable to prescribe Schedule II drugs in the state of Georgia. APRNs in Georgia are only allowed to prescribe Schedule III-V drugs. Regardless of which nurse protocol the APRN is practicing under, both protocols must include the following information: shall be in writing and signed by the advanced practice nurse and the delegating physician; shall be dated, available upon request, and specify parameters under which medical acts delegated by the physician may be performed; shall include provisions for periodic review of patient records by the delegating physician; shall be reviewed, revised or updated annually; shall include a provision for immediate consultation with the delegating physician or a physician designated in the absence of the delegating physician; hall contain written provisions regarding the procedure for dispensing dangerous drugs which comply with O.C.G.A. §§ 43-34-23(a)(3), (3.1), (4), and (5), if the dispensing of dangerous drugs is included as a delegated medical act in the nurse protocol agreement; and Shall contain written provisions regarding the procedure for ordering controlled substances which comply with paragraph (b)(1) of O.C.G.A. § 43-34-23, if the ordering of controlled substances is included as a delegated medical act in the nurse protocol agreement (Georgia Board of Nursing, 2021).

            Any medical provider that prescribes controlled substances must be registered with the federal Drug Enforcement Administration (DEA). This process can be done via the Drug Enforcement Administration's website. The online application consists of the following six components, personal information, email address validation, activity, state license (supervisory agreements, with specific authority for controlled substances), background information, application fee ($888) and confirmation (Drug Enforcement Administration, n.d.). This must be renewed every three years.

            The state of Georgia has a prescription drug monitoring program that is known as the Georgia Prescription Drug Monitoring Program (PDMP) is an online database that monitors and tracks the prescribing and dispensing of controlled substances in the state of Georgia (Georgia Department of Public Health, 2023). This information can be used to monitor a patient's-controlled substance history. All prescribers with an active Georgia professional license and active DEA number are required to register in the GA PDMP (Georgia Department of Public Health, 2023).

            According to Georgia Board of Nursing (2021), Georgia defines the scope of practice for a nurse practitioner as

“A nurse practitioner provides advanced practice nursing care and medical services specific to the nurse practitioner respective specialty to individuals, families and groups, emphasizing health promotion and disease prevention as well as the diagnosis and management of acute and chronic diseases. The nurse practitioner collaborates as necessary with a variety of individuals to diagnose and manage clients' health care problems (Georgia Board of Nursing, 2021).”

According to Hudspeth and Klein (2019), for safe practice and to optimize access to care, APRN's should have a clear and concise understanding of their board of nursing's standards of practice (SOP).

            When reviewing the licensure and certification for APRN for the state of Georgia I was surprised to learn about that Georgia has two different types of nurse-provider agreements. I also was surprised that the APRN must pay a fee to the medical board for the review of their supervision agreement. It seems that the medical board want to restrict the authority of APRNs in the state. Its very disheartening to be so restricted in Georgia, but I can move to a state like New York or New Mexico and have full authority. Overall, I feel that no matter the state, all APRNs should have the same authority. However, this is unlikely because medical boards and providers make money from the APRNs.  

                                                                 References

American Association of Nurse Practitioners. (2022, October). 
Georgia state policy fact sheet. Www.aanp.org. 

https://www.aanp.org/advocacy/state/state-practice-environment/state-policy-fact-sheets/georgia-state-policy-fact-sheetLinks to an external site.

Drug Enforcement Administration . (n.d.). 
Application for Registration Under Controlled Substances Act of 1970. Drug Enforcement Administration . 

https://apps.deadiversion.usdoj.gov/webforms2/spring/main?execution=e1s1Links to an external site.

Georgia Board of Nursing. (2021). 
Chapter 410-11:Regulation of Advanced Practice  Registered Nurses . Rules and Regulations of the State of Georgia. 

https://rules.sos.ga.gov/GAC/410-11Links to an external site.

Georgia Department of Public Health. (2023). 
Prescription drug monitoring program. Georgia Department of Public Health. 

https://dph.georgia.gov/pdmp#:~:text=The%20Georgia%20Prescription%20Drug%20Monitoring%20Program%20(PDMP)%20is%20an%20electronicLinks to an external site.

Hudspeth, R. S., & Klein, T. A. (2019). Understanding Nurse Practitioner Scope of Practice. 
Journal of the American Association of Nurse Practitioners, 
31(8), 468–473. 

https://doi.org/10.1097/jxx.0000000000000268Links to an external site.

 Reply

Using the patient on the case study below create a Comprehensive Psychiatric Evaluation Note on this patient using the template attached.

Case Study Anorexia Nervosa 

Please follow directions attached. Thank you