Case Study Assignment

Each diagnosis, primary, secondary and differential, includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to your patient. Pertinent lab results are interpreted within the rationale statement.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later (or article related to 2018 Guidelines) are used to support the primary diagnosis and develop the plan.

Every diagnosis rationale must include an in text citation to a scholarly reference. Each action step or order within all plan sections includes an in text citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included. Reference interpretation is accurate. Diagnoses plans are consistent with the guideline recommendations.

All ordered diagnostics tests are linked to a diagnosis and include a paraphrased EBP rationale with citation. Each diagnosis is included in the plan.

Plans are consistent with the guideline recommendations or scholarly reference.

Each prescribed and OTC medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale. Diagnosis is clearly stated in the rationale statement.

Plans are consistent with the guideline recommendations or scholarly reference

All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes personalized detailed education on diagnoses, medications, diet, exercise and warning signs. Personalized diet and exercise recommendations are included.

Plans are consistent with the guideline recommendations or scholarly reference.

All recommended referrals are appropriate for the patient diagnosis; each referral is linked to a specific diagnosis and includes a paraphrased EBP rationale.

Plans are consistent with the guideline recommendations or scholarly reference

Monthly medication costs are calculated and a total cost for the month’s medication is included.

All medications including OTCs are included.

Medication cost citation is included. Summary/reflection statement is included.

This SOAP note is an example of a patient chart entry. SOAP note included at end of assignment before the reference page.

SOAP note includes all elements and is formatted exactly as described in the Clinical SOAP note guidelines document. Rationales are not included. Only provided information is included in the SOAP note.

Paper is developed in a logical, meaningful, and understandable sequence using the provided assignment template

Rationale length does not exceed template directions. SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.

The paper does not exceed 20 pages.

Exceptional

Outstanding or highest level of performance

Exceeds

Very good or high level of performance

Meets

Satisfactory level of performance

Needs Improvement

Poor or failing level of performance

Developing

Unsatisfactory level of performance

Content

Possible Points = 180

All three diagnostic categories are present.

Each diagnosis, primary, secondary and differential, includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to your patient. Pertinent all lab results are interpreted within the rationale statement.

All three diagnostic categories are present.

Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement.

The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to your patient.

Pertinent lab or diagnostic results are not interpreted within the rationale statement.

All three diagnostic categories are present.

Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. Diagnosis is consistent with the guideline recommendations or scholarly reference.

The pathophysiology statement is not present or not paraphrased,

The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to your patient.

Pertinent lab or diagnostic results are not interpreted within the rationale statement.

Not all three diagnostic categories are developed: a primary, secondary or differential diagnosis category is not included.

Any diagnosis is not consistent with the guideline recommendations or scholarly reference.

OR

Includes treatment information

OR

Includes information that does not pertain to the case study patient such as pregnancy information or gender information that does not pertain to the case study patient’s listed gender or age.

Evidence-Based Practice

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later, (or article related to 2018 Guidelines) are used to support the primary diagnosis and develop the plan.

Every diagnosis rationale must include an in text citation to a scholarly reference. Each action step or order within all plan sections includes an in text citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included. Reference interpretation is accurate.

Diagnoses plans are consistent with the guideline recommendations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later, (or article related to 2018 Guidelines), are used to support the primary diagnosis and develop the plan.

Every diagnosis rationale must include an in text citation to a scholarly reference.

One or two steps or orders within all plan sections may be missing an in text citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.

Diagnoses plans are consistent with the guideline recommendations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later, (or article related to 2018 Guidelines), are used to support the primary diagnosis and develop the plan.

Every diagnosis rationale does not include an in text citation to an appropriate reference as listed in the Reference Guidelines document.

OR

One or two steps or orders within all plan sections may be missing an in text citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.

Diagnoses plans are consistent with the guideline recommendations.

The American Diabetes Association Standards and Medical Care in Diabetes-2018 or later (or article related to 2018 Guidelines) is not used to support the primary diagnosis.

OR

Not every diagnosis rationale includes an in-text citation to an appropriate reference as listed in the Reference Guidelines document. Reference interpretation is not accurate, diagnosis or plan is not consistent with the guideline recommendations.

OR

Three steps or orders within any/all plan section are missing an in text citation to an appropriate reference as listed in the Reference Guidelines document.

Scholarly information includes quotations.

Diagnoses and/or plan are not consistent with the guideline recommendations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2018 or later, (or article related to 2018 Guidelines) are not used as references.

All ordered diagnostics tests are linked to a diagnosis and include a paraphrased EBP rationale with citation. Each diagnosis is included in the plan.

Plans are consistent with the guideline recommendations or scholarly reference.

All ordered diagnostics tests are linked to a diagnosis listed in the assessment section and includes an EBP rationale.

Plans are consistent with the guideline recommendations or scholarly reference.

A diagnosis is not included within the rationale statement.

All ordered diagnostics tests are linked to a diagnosis listed in the assessment section.

Plans are consistent with the guideline recommendations or scholarly reference.

EBP rationale within text citation is missing;

OR

Rationale is a quotation.

Ordered diagnostics tests are not linked to a diagnosis listed in the assessment section

OR

Plans are not consistent with the guideline recommendations.

Each prescribed and OTC medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale. Diagnosis is clearly stated in the rationale statement.

Plans are consistent with the guideline recommendations or scholarly reference.

All prescribed and OTC medication include a paraphrased EBP rationale. The diagnosis is not clearly listed within the rationale statement.

Plans are consistent with the guideline recommendations or scholarly reference.

Each prescribed and OTC medication is linked to a specific diagnosis. The diagnosis is clearly listed within the rationale statement. An EBP rationale is not included

OR

Rationale is a quotation.

Plans are consistent with the guideline recommendations or scholarly reference.

Prescribed medications are listed but OTC medications are not present.

OR

Not every medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale.

OR

Plans are not consistent with the guideline recommendation or scholarly references.

All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes personalized detailed education on diagnoses, medications, diet, exercise and warning signs. Personalized diet and exercise recommendations are included.

Plans are consistent with the guideline recommendations or scholarly reference.

All education steps are linked to a diagnosis, paraphrased and include an EBP rationale.

One or 2 educational areas are not detailed or personalized to the patient.

Plans are consistent with the guideline recommendations or scholarly reference.

All education steps are linked to a diagnosis and includes an EBP rationale.

EBP rationale

is a quotation.

OR

Three (3) or more education areas do not include personalized detailed information or scholarly reference.

Plans are consistent with the guideline recommendations or scholarly reference.

Any education step is not linked to a diagnosis, not paraphrased or an EBP rational is not provided.

OR

Plans are not consistent with the guideline recommendations or scholarly reference.

All recommended referrals are appropriate for the patient diagnosis; each referral is linked to a specific diagnosis and includes a paraphrased EBP rationale.

Plans are consistent with the guideline recommendations or scholarly reference.

Some recommended referrals are appropriate for the patient diagnosis and condition, each referral is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering.

Plans are consistent with the guideline recommendations or scholarly reference.

All recommended referrals are appropriate for the patient diagnosis and condition, includes a paraphrased EBP rationale but specific diagnosis is not stated for every referral.

OR

EBP rationale

is a quotation.

Plans are consistent with the guideline recommendations or scholarly reference.

Some recommended referrals are appropriate for the patient diagnosis and condition

Does not include a paraphrased EBP rationale for referral.

OR

Plans are not consistent with the guideline recommendations.

Follow up is included in the plan but a specific time/date is not included (a range is included). Includes EBP rationale with in text citation. Only follow up information is listed in this section.

Plans are EBP and consistent with the guideline recommendations.

Follow up is included in the plan but a specific time is not included. Only follow up information is listed in this section.

Plans are consistent with the guideline recommendations.

Follow up is included in the plan; recommended follow up visit time frame is not EBP. Additional information, such as future testing, education or referrals are listed.

Plans are not consistent with the guideline recommendations.

SOAP note included at end of assignment before reference page.

SOAP note includes all elements and is formatted exactly as described in the SOAP note guidelines document. Rationales are not included. Only provided information is included in the SOAP note.

SOAP note included at end of assignment before reference page.

SOAP note includes all elements as listed in the SOAP note but not exactly as formatted in guidelines document.

Rationales are not included.

Only provided information is included in the SOAP note.

SOAP note included at end of assignment before the reference page.

SOAP note is formatted exactly as listed in the SOAP note guidelines document but is missing provided subjective or objective information. Subjective or objective information is not consistent with the case study. Provided information is missing or additional information is added to the SOAP note

SOAP note included, but not located at end of assignment before the reference page.

OR

SOAP note is not formatted exactly as shown in the SOAP note guidelines document and missing provided subjective or objective information.

Rationales are included.

Monthly medication costs are calculated and a total cost for the month’s medication is included.

All medications including OTCs are included.

Medication cost citation is included. Summary/reflection statement is included.

Monthly medication costs are calculated and a total cost for the month’s medications is included.

All medications including OTCs are included.

Medication cost reference is not included. Summary/reflection statement is included.

Monthly medication costs are calculated. A total cost for the month is included.

All medications including OTCs are included.

Summary/reflection statement is not included.

Monthly medication costs are calculated.

Summary statement/reflection is included.

Monthly medication costs are not totaled.

OR

OTCs are not included in monthly medication calculations.

Content Subtotal

Format

Possible Points = 20

Grammar, Syntax, APA

Paper is developed in a logical, meaningful, and understandable sequence using the provided assignment template

Rationale length does not exceed template directions.

SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.

The paper does not exceed 20 pages.

Assignment contains all elements but may not be written following provided assignment template

SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.

Each diagnosis and action step in the plan lists the step followed by the rationale. Rationale length does not exceed template directions.

The paper length does not exceed 20 pages.

Paper does not contain all components and/or may be missing data.

OR

SOAP note is not written in SOAP note format as outlined in the NR 601 SOAP note format document. Rationale length does not exceed template directions..

The paper length does not exceed 20 pages.

Paper is missing three or more required sections or

Diagnoses or

plans are sometimes unclear to follow and may not always be relevant to topic. Rationale length exceeds template directions.

OR

The paper exceeds 20 pages.

Paper is not relevant to case study patient

OR

SOAP note is not relevant to case study.

Participation

Assignment is submitted by the deadline Sunday @11:59 pm MT

Assignment submitted after the due date:

Deduction of 10% per day late up to 3 days after which a zero “0” will be recorded for the assignment.

One day late: -20 points

(Monday 12:00 am –Monday 11:59 PM MT)

Two day late: -40 points

(Tuesday 12:00 am –Tuesday 11:59 PM MT)

Three days late: -60 points

(Wednesday 12:00 am –Wednesday 11:59 PM MT)

After Wednesday 11:59pm MT- grade of zero

_____of 200 points

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