Rubic_Print_FormatCourse_CodeClass_CodeAssignment_TitleTotal

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Course Code	Class Code	Assignment Title	Total Points
HLT-362V	HLT-362V-O500	Quality Improvement Proposal	150.0
Criteria	Percentage	1: Unsatisfactory (0.00%)	2: Less Than Satisfactory (65.00%)	3: Satisfactory (75.00%)	4: Good (85.00%)	5: Excellent (100.00%)	Comments	Points Earned
Content	70.0%
Problem or Issue in Practice or Organization	5.0%	Overview of the problem and the setting in which the problem or issue occurs is not described.	Overview of the problem and the setting in which the problem or issue occurs is partially described. More information is needed to fully understand the problem and the scope of the organization or practice.	Overview of the problem and the setting in which the problem or issue occurs is summarized. Some information is needed to fully understand the problem or the scope of the organization or practice.	Overview of the problem and the setting in which the problem or issue occurs is described. Some detail is need for clarity.	Overview of the problem and the setting in which the problem or issue occurs is described in detail.
Significance of Quality Improvement in Practice or Organization	10.0%	Explanation of why the quality improvement initiative is needed is omitted.	Explanation of why the quality improvement initiative is needed is partially presented. More information is needed to understand why the quality improvement is relevant to the problem or setting. The expected outcome is unclear.	Explanation of why the quality improvement initiative is needed is summarized. Some information is needed to understand why the quality improvement is relevant to the problem or setting. The expected outcome is generally presented.	Explanation of why the quality improvement initiative is needed is discussed. It appears that the quality improvement initiative would help address the problem within the described setting. The expected outcome is described. Some information or rationale is needed for support or clarity.	Explanation of why the quality improvement initiative is need is clearly discussed. The quality improvement initiative would help address the problem within the described setting presented. The expected outcome is thoroughly described. Overall, the explanation is clear and well supported.
Demonstration of Support From Previous Research	15.0%	The use of research to demonstrate support for the quality improvement initiative and its projected outcomes is omitted. Three peer-reviewed sources published within the last 5 years are omitted.	The use of research to demonstrate support for the quality improvement initiative and its projected outcomes is incomplete. Overall, the research results do not demonstrate support for the initiative or projected outcomes. Fewer than three peer-reviewed sources published within the last 5 years were used.	The use of research to demonstrate support for the quality improvement initiative and its projected outcomes is generally presented. The research results generally demonstrate support for the initiative and projected outcomes. Three peer-reviewed sources published within the last 5 years were used.	The use of research to demonstrate support for the quality improvement initiative and its projected outcomes is presented. The research results demonstrate support for the initiative and projected outcomes. The three peer-reviewed sources meet all assignment criteria.	The use of research to demonstrate support for the quality improvement initiative and its projected outcomes is clearly presented. The research results strongly demonstrate support for the initiative and projected outcomes. The three peer-reviewed sources meet all assignment criteria and provide critical support for the initiative.
Steps Necessary to Implement Quality Improvement Initiative	15.0%	The steps necessary to implement the quality improvement initiative are omitted.	The steps necessary to implement the quality improvement initiative are incomplete. It is unclear how the steps presented will lead to implementation. More information is needed.	The steps necessary to implement the quality improvement initiative are summarized. Some steps are vague. More evidence or rationale is needed for support.	The steps necessary to implement the quality improvement initiative are discussed. Some evidence or rationale is needed for support or clarity.	The steps necessary to implement the quality improvement initiative are thoroughly discussed. The implantation steps are well supported with evidence and rationale.
Evaluation of Quality Improvement	15.0%	An explanation for how the quality improvement initiative will be measured is omitted.	An explanation for how the quality improvement initiative will be measured is partially presented. It is unclear how the evaluation will measure improvement; or it is unclear how the evaluation relates to the quality improvement initiative.	A general explanation for how the quality improvement initiative will be measured is summarized. The evaluation is generally appropriate to the quality improvement initiative.	An explanation for how the quality improvement initiative will be measured is presented. The evaluation is appropriate to the quality improvement initiative.	An explanation for how the quality improvement initiative will be measured is presented in detail. The evaluation is appropriate to the quality improvement initiative. Evaluation proposed is well supported.
Identification of Variables, Hypothesis Test, and Statistical Test	10.0%	The variables, hypothesis, and statistical tests needed to prove the quality improvement succeeded are omitted.	The variables, hypothesis, and statistical tests needed to prove the quality improvement succeeded are partially presented; one is omitted. The proposed elements are not relevant to proving the quality improvement succeeded.	The variables, hypothesis, and statistical tests needed to prove the quality improvement succeeded are summarized. There are inaccuracies.	The variables, hypothesis, and statistical tests needed to prove the quality improvement succeeded are presented. Overall, the proposed elements are relevant to proving the quality improvement succeeded.	The variables, hypothesis, and statistical tests needed to prove the quality improvement succeeded are presented and accurate. The proposed elements will prove whether the quality improvement succeeded.
Organization and Effectiveness	20.0%
Thesis Development and Purpose	7.0%	Paper lacks any discernible overall purpose or organizing claim.	Thesis is insufficiently developed or vague. Purpose is not clear.	Thesis is apparent and appropriate to purpose.	Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.	Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.
Argument Logic and Construction	8.0%	Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.	Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.	Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.	Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.	Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.
Mechanics of Writing (includes spelling, punctuation, grammar, language use)	5.0%	Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.	Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.	Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.	Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.	Writer is clearly in command of standard, written, academic English.
Format	10.0%
Paper Format (use of appropriate style for the major and assignment)	5.0%	Template is not used appropriately, or documentation format is rarely followed correctly.	Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent.	Appropriate template is used. Formatting is correct, although some minor errors may be present.	Appropriate template is fully used. There are virtually no errors in formatting style.	All format elements are correct.
Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)	5.0%	Sources are not documented.	Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.	Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.	Sources are documented, as appropriate to assignment and style, and format is mostly correct.	Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.
Total Weightage	100%

(Student Name)

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)

PATIENT INFORMATION

Name: Mr. DT

Age: 68-year-old

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: PCN, Iodine

Current Medications:

· Atorvastatin tab 20 mg, 1-tab PO at bedtime

· ASA 81mg po daily

· Multi-Vitamin Centrum Silver

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Preventive Care: Coloscopy 5 years ago (Negative)

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

Sexual Orientation: Straight

Nutrition History: Diets off and on, Does not each seafood

Subjective Data:

Chief Complaint: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.

CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data:

VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.

GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

ASSESSMENT:

Main Diagnosis

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017).

Differential diagnosis:

· Renal artery stenosis (ICD10 I70.1)

· Chronic kidney disease (ICD10 I12.9)

· Hyperthyroidism (ICD10 E05.90)

PLAN:

Labs and Diagnostic Test to be ordered:

· CMP

· Complete blood count (CBC)

· Lipid profile

· Thyroid-stimulating hormone (TSH)

· Urinalysis with Micro

· Electrocardiogram (EKG 12 lead)

Pharmacological treatment:

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

· Lisinopril 10mg PO Daily

Non-Pharmacologic treatment:

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP

· Instruction about medication intake compliance.

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

· Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.

· No referrals needed at this time.

References

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017

(25th ed.). Print (The 5-Minute Consult Series).

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