PRAC 6655 Assignment Clinical Hour and Patient Logs

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PRAC 6655 Assignment Clinical Hour and Patient Logs

PRAC 6655 Assignment Clinical Hour and Patient Logs

Clinical Hour Log
For this course, all practicum activity hours are logged within the Meditrek system. Hours

completed must be logged in Meditrek within 48 hours of completion in order to be
counted.
You may only log hours with Preceptors that are approved in Meditrek. Students with
catalog years before Spring 2018 must complete a minimum of 576 hours of supervised
clinical experience (144 hours in each practicum course). Students with catalog years
beginning Spring 2018 must complete a minimum of 640 hours of supervised clinical
experience (160 hours in each practicum course).
Each log entry must be linked with an individual practicum Learning Objective or a
graduate Program Objective. You should track your hours in Meditrek as they are
completed.
Your clinical hour log must include the following:
 Dates
 Course
 Clinical Faculty
 Preceptor
 Total Time (for the day)
 Notes/Comments (including the objective to which the log entry is aligned)
Patient Log
Throughout this course, you will also keep a log of patient encounters using Meditrek. You
must record at least 80 encounters with patients by the end of this practicum (40
children/adolescents and 40 adult/older adult).
The patient log must include the following:
 Date
 Course
 Clinical Faculty
 Preceptor
 Patient Number
 Client Information
 Visit Information
 Practice Management
 Diagnosis

 Treatment Plan and Notes: You must include a brief summary/synopsis of the
patient visit. This does not need to be a SOAP note, however the note needs to be
sufficient to remember your patient encounter.
By Day 7 of Week 3
Record your clinical hours and patient encounters in Meditrek.

Assignment 2: Focused SOAP Note and Patient Case Presentation

Photo Credit: Pexels
Psychiatric notes are a way to reflect on your practicum experiences and connect them to
the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the
ones required in this practicum course, are often used in clinical settings to document
patient care.
For this Assignment, you will document information about a patient that you examined
during the last three weeks, using the Focused SOAP Note Template provided. You will
then use this note to develop and record a case presentation for this patient.
To Prepare
 Review this week's Learning Resources and consider the insights they provide. Also
review the Kaltura Media Uploader resource in the left-hand navigation of the
classroom for help creating your self-recorded Kaltura video.
 Select a patient of any age (either a child or an adult) that you examined during the
last 3 weeks.
 Create a Focused SOAP Note on this patient using the template provided in the
Learning Resources. There is also a completed Focused SOAP Note Exemplar
provided to serve as a guide to assignment expectations.
Please Note:

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o All SOAP notes must be signed, and each page must be initialed by your
Preceptor. Note: Electronic signatures are not accepted.

PRAC 6655 Assignment Clinical Hour and Patient Logs

PRAC 6655 Assignment Clinical Hour and Patient Logs

o When you submit your note, you should include the complete focused SOAP
note as a Word document and PDF/images of each page that is initialed and
signed by your Preceptor.
o You must submit your SOAP note using SafeAssign. Note: If both files are
not received by the due date, faculty will deduct points per the Walden
Grading Policy.

 Then, based on your SOAP note of this patient, develop a video case study
presentation. Take time to practice your presentation before you record.
 Include at least five scholarly resources to support your assessment, diagnosis, and
treatment planning.
 Ensure that you have the appropriate lighting and equipment to record the
presentation.
The Assignment
Record yourself presenting the complex case study for your clinical patient. In your
presentation:
 Dress professionally with a lab coat and present yourself in a professional manner.
 Display your photo ID at the start of the video when you introduce yourself.
 Ensure that you do not include any information that violates the principles of
HIPAA (i.e., don’t use the patient’s name or any other identifying information).
 Present the full complex case study. Include chief complaint; history of present
illness; any pertinent past psychiatric, substance use, medical, social, family history;
most recent mental status exam; current psychiatric diagnosis including
differentials that were ruled out; and plan for treatment and management.
 Report normal diagnostic results as the name of the test and “normal” (rather than
specific value). Abnormal results should be reported as a specific value.
 Be succinct in your presentation, and do not exceed 8 minutes. Specifically address
the following for the patient, using your SOAP note as a guide:
o Subjective: What details did the patient provide regarding their chief
complaint and symptomology to derive your differential diagnosis? What is
the duration and severity of their symptoms? How are their symptoms
impacting their functioning in life?
o Objective: What observations did you make during the psychiatric
assessment?
o Assessment: Discuss their mental status examination results. What were your
differential diagnoses? Provide a minimum of three possible diagnoses and
why you chose them. List them from highest priority to lowest priority. What
was your primary diagnosis and why? Describe how your primary diagnosis
aligns with DSM-5 diagnostic criteria and supported by the patient’s
symptoms.
o Plan: What was your plan for psychotherapy? What was your plan for
treatment and management, including alternative therapies? Include
pharmacologic and nonpharmacologic treatments, alternative therapies, and

follow-up parameters, as well as a rationale for this treatment and
management plan. Also be sure to include at least one health promotion
activity and one patient education strategy.
o Reflection notes: What would you do differently with this patient if you could
conduct the session again? If you are able to follow up with your patient,
explain whether these interventions were successful and why or why not. If
you were not able to conduct a follow up, discuss what your next intervention
would be.
By Day 7 of Week 3
Submit your Video and Focused SOAP Note Assignment. You must submit two files for the
note, including a Word document and scanned pdf/images of each page that is initialed and
signed by your Preceptor.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
 Please save your Assignment using the naming convention “WK3Assgn2+last
name+first initial.(extension)” as the name.
 Click the Week 3 Assignment 2 Rubric to review the Grading Criteria for the
Assignment.
 Click the Week 3 Assignment 2 link. You will also be able to “View Rubric” for
grading criteria from this area.
 Next, from the Attach File area, click on the Browse My Computer button. Find the
document you saved as “WK3Assgn2+last name+first initial.(extension)” and
click Open.
 If applicable: From the Plagiarism Tools area, click the checkbox for I agree to
submit my paper(s) to the Global Reference Database.
 Click on the Submit button to complete your submission.
Grading Criteria

To access your rubric:
Week 3 Assignment 2 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:
Submit your Week 3 Assignment 2 draft and review the originality report.

Submit Your Assignment by Day 7 of Week 3

To participate in this Assignment:
Week 3 Assignment 2

What’s Coming Up in Week 4?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will continue your clinical hour and patient logs in Meditrek. The week’s
resource selections will support your knowledge of assessing and treating mood disorders.
Next Week

To go to the next week:
Week 4

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