School of Nursing and Allied Health
\nMSN Case Write Up Assignment
\nThe purpose of the Case Write-Up Assignment is for your instructor to “see” what you are doing in clinical and “see” how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will \u201cwrite-up\u201d the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.
\nMake sure to start \u201cfresh\u201d. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.
\nBe honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, add an addendum at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice. Be truthful in your writing. If you realize that you forgot to evaluate something or teach a certain part of the lesson, you can add an addendum to the end of the paper explaining what you should have done. Your clinical instructors don’t expect you to have perfect write-ups, but they do expect you to use every patient encounter and write-up that follows as a chance to learn, evaluate, and improve your own practice.<\/p>\n
If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write an addendum at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum.<\/p>\n
You are learning to practice evidence-based practice. Support the assessment AND plan with research. This can be your textbook and\/or other class readings. The best way to support your write up is using a research article. Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)
\nNote that you CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups
\nAll case write ups are to be submitted to the appropriate assignment category by the due date. Late submissions to the appropriate assignment category will incur a 5pt\/day penalty (no maximum) including weekends unless an extension has been requested and approved before the due date.
\nWhen submitting case write up in Blackboard, the assignment will submit to a plagiarism detection software. The plagiarism detection software is used by HBU to identify plagiarized assignments. We are aware of the difference between high “copy matches” due to copied things such as titles\/headings and significant matches that were inappropriately copied from another paper. Unfortunately, we have seen some of the latter and it is generally not difficult to tell the difference between the two since we can immediately see every word of the other papers. If a paper has significant or complete sections of copied material, a grade of zero will be assigned to the paper.
\nEpisodic Write-up: Episodic visits are mostly encounters which involve one time visit (sometimes with a short follow-up depending on the diagnosis\/existing comorbidities), or occurs occasionally. Episodic visit ROS and physical examination (PE) are targeted and focused on the body system(s) affected. Examples are URI, bronchitis, seasonal allergic rhinitis, acute pharyngitis, acute gastroenteritis, pneumonia, contact dermatitis, etc.<\/p>\n
This write-up should be 2-5 pages (excluding title page and reference list) and concentrate on the most pertinent information. Not all the systems or sections will be represented. Only the sections and information that are important to this case need be included. This helps clarify your understanding of using only the best\/most important tools and information to justify your critical thinking.
\nComprehensive Write-up: Comprehensive visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam (may not always include head to toe, but could be the only preventive care most women receive), well child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc. This write up should be 5-8 pages (excluding title page and reference list).
\nYou must know how to delineate which visits are episodic versus comprehensive. Conducting a comprehensive exam on a patient whose chief complaint and ROS support an episodic visit or write-up may paint a picture of a clueless provider; and can constitute a waste of time for you and the patient. Your patient may not trust your clinical reasoning\/judgment (diagnosis\/plan of care) if they perceive you are all over the place! Insurance is not going to pay you more because you decided to complete a comprehensive note on an episodic visit or diagnosis!
\nAlternative Write-up: Some courses may have specialized write-ups based on a patient with certain demographics or with certain disease process. These write ups will follow the same guidelines as comprehensive-write ups.
\nThis assignment is designed to promote the development of the following: AACN Essentials (2022): Domains 1, 2, 4, 6, and 9 and NONPF NP Core and Population-Focused Competencies (2012;2017): Scientific Foundational, Practice Inquiry, Technology and Information Literacy, and Independent Practice.
\nCase Write-up Outline<\/p>\n
Following the format of: https:\/\/meded.ucsd.edu\/clinicalmed\/write.htm.<\/p>\n
Subjective:
\nCC: This should be in quotes: \u201cI\u2019ve had a cough and sore throat for 2 days\u201d
\nHPI: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases.
\nPast Medical History: Past or present illness. Be careful with \u201cblindly\u201d copying history from a prior clinical note.
\nPast Hospitalizations: Past hospitalizations with reason for admit, duration of stay, and rough dates
\nPast Surgical History: Past surgeries and rough dates when possible.
\nMedications: List name, dose, frequency and indication (why are they taking it?). Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether you\u2019ve put all important information in your patient history. If a patient is taking Metformin and there\u2019s no related information on the history and\/or diagnoses list, something is missing.
\nAllergies: Medications, Food allergies when applicable. Specify what type of reaction next to the allergy if known by the person you are collecting history from (E.g., Penicillin-rash)
\nSocial History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunization is important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, don\u2019t just say UTD. For pediatrics: list dates for all immunizations.
\nOther pediatric considerations: list who all lives in home with patient, how many siblings with ages next to them, type of home, any pets inside\/outside home & what type of pet, any smoking in home, any guns in home; if young child: are they in daycare or if babysitter or family member or parent stay home with child, are they in school & what grade and what type of grades the child makes, list any extracurricular activities, any problems with school or teacher, any recent social or home changes. If they are pre-teen and older- add alcohol use, smoking, sexual history, work history, etc.
\nFamily History: It is generally appropriate to go back at least two generations. State family member (mom\/dad\/maternal grandparents\/paternal grandparents\/siblings\/etc.), their age & if they\u2019re alive, write unknown if history not known, write any conditions or illnesses next to each person, if they are deceased write deceased and any illnesses\/conditions for them also.
\nObstetrical History: When appropriate, document number of pregnancies and other relevant information.
\nBirth History \u2013 applicable for pediatric write ups especially for young pediatric patients
\nReview of Symptoms (ROS): For comprehensive visits: should be extensive and include every system. For episodic visits: Think about your likely differential diagnosis list and tailor your ROS to it. Always address growth and development in pediatric patients. Nutrition should be addressed, especially in pediatric patients. In childbearing women (any teen or female who have reached menarche), make sure to document date of last menstrual period (LMP) and methods of contraceptive use on every visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation\/hysterectomy). Every visit – If you order such a medication without documenting the above information, we have to assume that the patient could be pregnant (as would any lawyer in a lawsuit). For a young teen you can put \u201cnot sexually active\u201d (but make sure you have asked). This is sometimes tricky with teens being seen for general health problems but so very important. If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone.
\nObjective
\nVital signs (BMI should be included on every visit)
\nPhysical examination
\n\u2022\tEpisodic exam: make sure that you detail your findings for each system pertinent to your Chief Complaint. E.g., if you have a child pulling on their ears, it will NOT look good if you do not document an ear assessment or otoscopic examination in your physical exam for your write-up.
\n\u2022\tComprehensive exam: This is head to toe detailed and thoroughly describe findings within ALL systems.
\nLaboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but not results were not available.
\nTIP:
\nMake sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, Social\/family history, and Review of system (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and\/or diagnostic test results. Note that statement such as \u201cDenies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.\u201d should be in the subjective section (ROS) of your note, and not in PE section. Do not write \u201cAlert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature\u201d under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.
\nAssessment
\nList both your differential diagnoses and your presumptive diagnosis \u2013 include appropriate ICD-10 codes for all diagnoses. Remember that these should be supported by findings in your history and physical exam. For a comprehensive visit, you should document at least three ICD code diagnoses. Occasionally, a comprehensive visit merits a differential diagnosis list. If your ROS or physical exam findings reveal abnormalities, the abnormalities need to be addressed.
\nPlease remember support your indicated diagnoses with evidence-based reference: provide citation and supportive information.
\nPlan
\nInclude medications ordered, labs tests, teaching, referrals, and when the patient needs to follow-up. All write-up plans should include documentation of patient education, especially if medication is prescribed and anticipatory guidance. Health maintenance such as screening for breast or colon cancer, should be addressed. Please be sure this information is organized under each diagnosis; keeping it organized helps the write up flow well to where the reader is able to get a clear picture of everything you did during the patient encounter.<\/p>\n
Coding Resource:
\nAll write ups should include the billing codes. We do not expect you to memorize these codes. You can get them from the billing form that the physician or NPs uses in the office. You can put the billing codes at the end of the write-up \u2013 do not forget to include both the E&M code (level of service). Your E&M code should be consistent with your patient visit.
\nAddendum
\n***Remember to add an additional note at the end of the write up if you realized anything was missing from the encounter that should have been done or ordered. Put it at the end of your write up and label it: Addendum ***<\/p>\n
MSN Case Write-Up Rubric<\/p>\n
Criteria\tExceeds Expectations\tMeets Expectations\tBelow Expectations\tNo Effort
\nChief Complaint
\n(CC)\t3 Points
\n\u2022\tIncludes the reason for visit
\n\u2022\tCC is appropriate for the type of write-up
\n\u2022\tCC is in the patient\/family\u2019s own words. \t2 Points
\n\u2022\tCC is not in the patient\/family\u2019s own words
\n1 Point
\n\u2022\tCC is not appropriate for the type of write-up\t0 Points
\n\u2022\tNot included
\nHistory of Present Illness
\n(HPI)\t10 points
\n\u2022\tHPI is comprehensive and includes all the pertinent information and excludes irrelevant information.
\n\u2022\tHPI is focused and detailed.
\n7 points
\n\u2022\tMissing 1-2 key components
\nOR
\n\u2022\tIncludes information that is irrelevant to the patient visit. \t4 points
\n\u2022\tMissing 3 or more key components
\nOR
\n\u2022\tHPI is not focused and lacks details\t0 Points
\n\u2022\tNot included
\nMedications\t3 Points
\n\u2022\tMedication list is comprehensive and includes scheduled and PRN drug name (brand and generic), dosage, route, frequency and indication.
\n\u2022\tAllergies are documented and includes reaction.
\n\u2022\tIncludes NDKA, if applicable.\t2 Points
\n\u2022\tOmits 1-2 details.
\nOR
\n\u2022\tAllergies are documented but does not include reaction.\t1 Point
\n\u2022\tOmits 3 or more details.
\nOR
\n\u2022\tAllergies are not addressed\t0 Points
\n\u2022\tNot included
\nPertinent History\t10 Points
\n\u2022\tProvides comprehensive past medical history, surgical, family, social, obstetrical history, and birth history (when applicable).
\n\u2022\tHistory is consistent with other documentation.
\n\u2022\tIncludes immunization information
\n7 Points
\n\u2022\tOmits 1 -2 pertinent details
\n4 Points
\n\u2022\tHistory presented is superficial
\nOR
\n\u2022\tOmits 3 or more pertinent details
\n0 Points
\n\u2022\tNot included
\nReview of Systems\t10 Points
\n\u2022\tROS is completed in a systematic fashion
\n\u2022\tFor episodic visit:
\n1. ROS addresses at least 4 systems. 2. ROS is specific to the patient\u2019s problems and likely differential diagnoses
\n\u2022\tFor comprehensive visit: each system is addressed completely
\n\u2022\tDoes not include any objective data
\n\u2022\tDo not write within normal limit or other variations. If documented abnormalities, states what is considered \u2018normal\u2019\t7 Points
\n\u2022\tMisses 1-2 components
\nOR
\n\u2022\tROS includes inappropriate systems for an episodic visit
\n4 Points
\n\u2022\tMisses 3 or more components
\nOR
\n\u2022\tROS includes objective data
\n0 Points
\n\u2022\tNo ROS attempted
\nObjective Data\t18 Points
\n\u2022\tDocuments vital signs with BMI included<\/p>\n
\u2022\tFor episodic visit:
\n1.\tPE addresses at least 4 body systems
\n2.\tPE is specific to the patient\u2019s problem and likely differential diagnoses
\n\u2022\tFor comprehensive visit: each system addressed completely<\/p>\n
\u2022\tIncludes pertinent positive and pertinent negative findings.<\/p>\n
\u2022\tDoes not include any subjective data<\/p>\n
\u2022\tDocuments labs, diagnostic tests that are available for that visit.<\/p>\n
\u2022\tDo not write within normal limit or other variations. If documented abnormalities, states what is considered \u2018normal\u2019\t12 Points
\n\u2022\tDocuments vital signs but is missing BMI
\nOR
\n\u2022\tMissing 2-3 components, pertinent positives\/negatives
\nOR
\n\u2022\tPE includes unnecessary systems for an episodic visit
\nOR
\n\u2022\tPlan includes subjective data
\nOR
\n\u2022\tDocuments labs, diagnostic tests that should be a part of the plan
\n6 Points
\n\u2022\tDoes not document vital signs
\nOR
\n\u2022\tMissing 4 or more of the components, pertinent positives\/negatives
\nOR
\n\u2022\tIncludes unnecessary systems for an episodic visit
\nOR
\n\u2022\tAddresses less than 4 systems for an episodic visit<\/p>\n
\u2022\tFails to document labs, diagnostic tests<\/p>\n
0 Points<\/p>\n
\u2022\tNot included
\nAssessment\t16 Points
\n\u2022\tProvides 3 or more differential diagnoses and a presumptive diagnosis for an episodic visit.<\/p>\n
\u2022\tProvides at least 3 diagnoses for a comprehensive visit<\/p>\n
\u2022\tDiagnoses are accurate and appropriate for the patient visit<\/p>\n
\u2022\tICD-10 codes included with each diagnosis\t10 Points
\n\u2022\tProvides only 2 differential diagnoses for an episodic visit
\nOR
\n\u2022\tProvides less than 3 diagnoses for a comprehensive visit
\nOR
\n\u2022\tFails to provide differential diagnoses for abnormal findings in a comprehensive visit<\/p>\n
\u2022\tDoes not include ICD-10 codes
\n6 Points
\n\u2022\tProvides only 1 diagnosis for an episodic visit
\nOR
\n\u2022\tDiagnoses provided are not appropriate for the patient visit
\n0 Points
\n\u2022\tNo effort
\nPlan\t20 Points
\n\u2022\tPlan is thorough and includes appropriate labs\/tests ordered that are pending<\/p>\n
\u2022\tIncludes medications ordered and\/or refilled and details about dosing and instructions, and patient teaching are included.<\/p>\n
\u2022\tPlan includes both pharmacological and non-pharmacological interventions<\/p>\n
\u2022\tPlan includes referrals (when applicable) and follow up details<\/p>\n
\u2022\tOrders are appropriate for patient visit.<\/p>\n
\u2022\tCitations for sources of interventions<\/p>\n
\u2022\tCoding and Billing included
\n15 Points
\n\u2022\tMissing 1-2 components
\nOR
\n\u2022\tDoes not include Coding and Billing
\n10 Points
\n\u2022\tPlan is superficial
\nOR
\n\u2022\tMissing 3 or more components
\nOR
\n\u2022\tPlan is not supported by evidence and citations for sources of intervention are missing\t0 Points
\n\u2022\tNot included or inappropriate to patient visit
\nFormatting\/APA\t10 Points
\n\u2022\tNo errors in grammar and spelling .<\/p>\n
\u2022\tNo errors in APA format<\/p>\n
\u2022\tWrite-up is in proper format and adheres to the appropriate page limits.\t7 Points
\n\u2022\t1-2 spelling or grammar errors
\nOR
\n\u2022\t1-2 APA errors\t4 Points
\n\u2022\t3-4 errors in spelling or grammar
\nOR
\n\u2022\t3-4 APA errors
\nOR
\n\u2022\tWrite-up is not in proper format
\nOR
\n\u2022\tWrite-up does not adhere to the appropriate page limits
\n0 Points
\n\u2022\t5 or more errors in spelling or grammar
\nOR
\n\u2022\t5 or more APA errors<\/p>\n","protected":false},"excerpt":{"rendered":"
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