Medical / nursing Writing Services
case study on a patient who is having aortic valve replacement in icu need of rationale with references for treatment Rubric for Written Note Objective Points Objective met Objective not met Comments 1) States “cc” reason for admission and chronological order the HPI 0.5 2) PMH /PSH/PFH 1 3) Social/Smoking history/allergies 1 4) Medication history (home & hospital) 1 5) ROS- pertinent 1 6) Physical exam 1 7) Reviews pertinent laboratory data (explains abnormal & relevance to the patient 1 8) Differential Diagnosis (Assessment) 1 9) Plan- appropriate tests, treatment modalities which include rationale 1.5 10) Documents appropriate source of EBP 1 Total score Please remember to give rationale for assessment and plan using best practice guidelines. Please do NOT change your note to fit this rubric. As long as the note has the above listed components you will meet the requirements.
