The Role of the RN/APRN in Policy Evaluation
Health policies easily influence the health of the public (Pollack et al., 2018). The policies touch on the very essential aspects of health as well as determinants of health. Therefore, it would be very prudent to ensure that there is evidence in health policies. Differently put, it would be prudent to make sure that evidence-based findings and guidelines are considered in the making and implementation of health policies. Notably, this should not be the end. During the implementation of the policy and after a particular while, there is a need to evaluate or review the policy in order to make sure that it has been having the desired effects. Data should be collected and ways of policy evaluation established in order to make sure that if gaps still exist, the policy can be adjusted or amended in order to close these gaps.
Policy Review Issues and Related Social Determinants of Health
Many opportunities for policy review exist. For instance, nurses are already aware of the existing health policies and what the intentions of the lawmakers were when they implemented the policy. The nurses themselves could have been integral in the making of the policy. As such, they will have a clear picture of what was intended. However, after a while, it may be clear that there are gaps in policies. This can be established through policy review. In fact, during the making of the policies, nurses should always recommend that a review should be implemented after a particular period. This is necessary in order to maximize the expected outcomes of the policy. Nurses should be able to see the bigger picture (Salvage & White, 2019). This is how they will always find policy gaps and see the need for a review. A good example is in regard to many policies or food programs implemented in schools with the view of reducing childhood obesity. Indeed, many local polices have been implemented to this effect. In a review of such policies, evidence showed that some were effective in improving diet as well as the food environment in schools. However, there was limited evaluation of how the policies impacted BMI (Jaime & Lock, 2019). With the knowledge of such gaps in local and state policies, nurses can suggest evidenced-based interventions to review the policies in order to ensure that they actually have the expected outcomes. When it comes to social determinants of health that affect this issue, income and education level greatly impact food intake and body weight, especially in minority communities. Secondly, conducting community health assessments may allow nurses to identify the need to review specific programs or policies. Such assessments help to identify the needs of the community and help to come up with strategies of how the needs can be met. This is a great opportunity to review existing policies in order to ensure that they actually help health providers in meeting the emerging health needs of a population (Stoto et al., 2019).
Possible Challenges
One challenge that may present is lack of interest by nurses to be involved in the review. Nurses may be involved in policy making and see as if this is the end. According to Salvage and white (2019), while policy as well as politics determine health and nursing practice, most nurses just want to get on with their jobs. If there is nobody that is interested in the review process, it shall not be done. To overcome this, nurses should be encouraged to have a sustainable approach to policy involvement. This entails not only policy making but also policy review. Another challenge is that nurses may not have adequate knowledge on what policy review entails. Therefore, they should be educated about this and how to participate in the same.
Communicating the Existence of Opportunities and Addressing Challenges
The existence of opportunities needs to be communicated during nursing education. As they are trained about policy-making and policy-review, they should also be informed about existing opportunities. Again, just like in policy making, professional organizations should also be involved as ways of communicating the opportunities. Professional nursing organizations are proactive in advocating for the needs of the clients as well as nurses (Matthews, 2012).
References
Jaime, P. C., & Lock, K. (2019). Do school based food and nutrition policies improve diet and reduce obesity? Preventive Medicine,48(1), 45-53.
Matthews, J. (2012). Role of professional organizations in advocating for the nursing profession.Online J Issues Nurs,17(3).
Pollack Porter, K. M., Rutkow, L., & McGinty, E. E. (2018). The importance of policy change for addressing public health problems.Public Health Reports,133(1_suppl), 9S-14S.
Salvage, J., & White, J. (2019). Nursing leadership and health policy: everybody’s business.International Nursing Review,66(2), 147-150
Stoto, M. A., Davis, M. V., & Atkins, A. (2019). Making better use of population health data for community health needs assessments.eGEMs,7(1).

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Episodic case write up – 3 pages

Directions in attachment

School of Nursing and Allied Health
MSN Case Write Up Assignment
The 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 write-up 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.
Make sure to start fresh. 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.
Be 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 improveyour own practice.

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.

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 apoint penalty reduction (see rubric for additional information)

Note 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

All 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.
When 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 copiedfrom another paper. Unfortunately, we have seen some of the latter and itis 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 sectionsof copied material, a grade of zero will be assigned to the paper.

EpisodicWrite-up: Episodicvisits are mostly encounters which involve one time visit (sometimes with a short follow-up depending on the diagnosis/existing comorbidities), or occurs occasionally. Episodicvisit 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.

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.

Comprehensive 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).

You must know how to delineate which visits areepisodicversus comprehensive. Conducting a comprehensive exam on a patient whose chief complaint and ROS support anepisodicvisit 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 anepisodicvisit or diagnosis!

Alternative 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.

This 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.

Case Write-up Outline

Following the format of:
https://meded.ucsd.edu/clinicalmed/write.htm.

Subjective:

CC: This should be in quotes: Ive had a cough and sore throat for 2 days
HPI: 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.
Past Medical History: Past or present illness. Be careful with blindly copying history from a prior clinical note.
Past Hospitalizations: Past hospitalizations with reason for admit, duration of stay, and rough dates
Past Surgical History: Past surgeries and rough dates when possible.
Medications: 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 youve put all important information in your patient history. If a patient is taking Metformin and theres no related information on the history and/or diagnoses list, something is missing.
Allergies: 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)
Social 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, dont just say UTD. For pediatrics: list dates for all immunizations.
Other 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.
Family 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 theyre 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.
Obstetrical History: When appropriate, document number of pregnancies and other relevant information.
Birth History applicable for pediatric write ups especially for young pediatric patients
Review 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 not sexually active (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.

Objective

Vital signs (BMI should be included on every visit)
Physical examination
Episodic 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.
Comprehensive exam: This is head to toe detailed and thoroughly describe findings within ALL systems.
Laboratory 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.
TIP:
Make 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 Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc. should be in the subjective section (ROS) of your note, and not in PE section. Do not write Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.

Assessment

List both your differential diagnoses and your presumptive diagnosis 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.
Please remember support your indicated diagnoses with evidence-based reference: provide citation and supportive information.

Plan

Include 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.

Coding Resource:

All 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 do not forget to include both the E&M code (level of service). Your E&M code should be consistent with your patient visit.
Addendum

***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 ***

MSN Case Write-Up Rubric

Criteria

Exceeds Expectations

Meets Expectations

Below Expectations

No Effort

Chief Complaint
(CC)

3 Points
Includes the reason for visit
CC is appropriate for the type of write-up
CC is in the patient/familys own words.

2 Points
CC is not in the patient/familys own words

1 Point
CC is not appropriate for the type of write-up

0 Points
Not included

History of Present Illness
(HPI)

10 points
HPI is comprehensive and includes all the pertinent information and excludes irrelevant information.
HPI is focused and detailed.

7 points
Missing 1-2 key components
OR
Includes information that is irrelevant to the patient visit.

4 points
Missing 3 or more key components
OR
HPI is not focused and lacks details

0 Points
Not included

Medications

3 Points
Medication list is comprehensive and includes scheduled and PRN drug name (brand and generic), dosage, route, frequency and indication.
Allergies are documented and includes reaction.
Includes NDKA, if applicable.

2 Points
Omits 1-2 details.
OR
Allergies are documented but does not include reaction.

1 Point
Omits 3 or more details.
OR
Allergies are not addressed

0 Points
Not included

Pertinent History

10 Points
Provides comprehensive past medical history, surgical, family, social, obstetrical history, and birth history (when applicable).
History is consistent with other documentation.
Includes immunization information

7 Points
Omits 1 -2 pertinent details

4 Points
History presented is superficial
OR
Omits 3 or more pertinent details

0 Points
Not included

Review of Systems

10 Points
ROS is completed in a systematic fashion
For episodic visit:
1. ROS addresses at least 4 systems. 2. ROS is specific to the patients problems and likely differential diagnoses
For comprehensive visit: each system is addressed completely
Does not include any objective data
Do not write within normal limit or other variations. If documented abnormalities, states what is considered normal

7 Points
Misses 1-2 components
OR
ROS includes inappropriate systems for an episodic visit

4 Points
Misses 3 or more components
OR
ROS includes objective data

0 Points
No ROS attempted

Objective Data

18 Points
Documents vital signs with BMI included

For episodic visit:
1. PE addresses at least 4 body systems
2. PE is specific to the patients problem and likely differential diagnoses
For comprehensive visit: each system addressed completely

Includes pertinent positive and pertinent negative findings.

Does not include any subjective data

Documents labs, diagnostic tests that are available for that visit.

Do not write within normal limit or other variations. If documented abnormalities, states what is considered normal

12 Points
Documents vital signs but is missing BMI
OR
Missing 2-3 components, pertinent positives/negatives
OR
PE includes unnecessary systems for an episodic visit
OR
Plan includes subjective data
OR
Documents labs, diagnostic tests that should be a part of the plan

6 Points
Does not document vital signs
OR
Missing 4 or more of the components, pertinent positives/negatives
OR
Includes unnecessary systems for an episodic visit
OR
Addresses less than 4 systems for an episodic visit

Fails to document labs, diagnostic tests

0 Points

Not included

Assessment

16 Points
Provides 3 or more differential diagnoses and a presumptive diagnosis for an episodic visit.

Provides at least 3 diagnoses for a comprehensive visit

Diagnoses are accurate and appropriate for the patient visit

ICD-10 codes included with each diagnosis

10 Points
Provides only 2 differential diagnoses for an episodic visit
OR
Provides less than 3 diagnoses for a comprehensive visit
OR
Fails to provide differential diagnoses for abnormal findings in a comprehensive visit

Does not include ICD-10 codes

6 Points
Provides only 1 diagnosis for an episodic visit
OR
Diagnoses provided are not appropriate for the patient visit

0 Points
No effort

Plan

20 Points
Plan is thorough and includes appropriate labs/tests ordered that are pending

Includes medications ordered and/or refilled and details about dosing and instructions, and patient teaching are included.

Plan includes both pharmacological and non-pharmacological interventions

Plan includes referrals (when applicable) and follow up details

Orders are appropriate for patient visit.

Citations for sources of interventions

Coding and Billing included

15 Points
Missing 1-2 components
OR
Does not include Coding and Billing

10 Points
Plan is superficial
OR
Missing 3 or more components
OR
Plan is not supported by evidence and citations for sources of intervention are missing

0 Points
Not included or inappropriate to patient visit

Formatting/APA

10 Points
No errors in grammar and spelling .

No errors in APA format

Write-up is in proper format and adheres to the appropriate page limits.

7 Points
1-2 spelling or grammar errors
OR
1-2 APA errors

4 Points
3-4 errors in spelling or grammar
OR
3-4 APA errors
OR
Write-up is not in proper format
OR
Write-up does not adhere to the appropriate page limits

0 Points
5 or more errors in spelling or grammar
OR
5 or more APA errors

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