Musculoskeletal Focused Note

Musculoskeletal Focused Note

For this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks. You will complete your third Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, previous medical history (PMH), socio-economic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes. Check tips on how to do your SOAP Note Writing Services.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

To prepare:

Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this assignment.

Select a patient that you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following in a Focused Note:

Musculoskeletal Focused Note

Assignment:

Subjective: What details did the patient provide regarding her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

Reflection notes: What would you do differently in a similar patient evaluation?