Order ID:89JHGSJE83839 | Style:APA/MLA/Harvard/Chicago | Pages:5-10 |
Instructions:
Case Study for SOAPIER Note.
Read the case study. Write a progress note using the SOAPIER format.
SJ came to the ER you are working at with complaint of severe pain in his left leg. When you asked him what happened, he said I was sled riding in the snow with some friends. I lost control and went over the hill and hit a tree. My leg is killing me.
You do an assessment. SJ is alert and oriented to person, place and time. He has no known allergies (NKA).Skin is warm and dry. Color appropriate for ethnicity. Neuro checks are normal. Denies hitting his head. Has full range of motion in both arm and right leg. EMS has a stabilizing splint on his right leg. Bilateral toes are pink and capillary refill is quick to return. Distal extremities pulses are strong and bounding. Bowel sounds are positive in all four quadrants.
Vital signs are 97.8 orally. Heart rate is 110 and regular. Heart sounds S1 and S2 heard. Respirations are 24 and unlabored. Lung sounds are clear. Blood pressure is 172/96. He asks Please can you give me something for pain? Rates his pain a 10 on the 0 -10 numeric scale. You give him 4 milligrams of morphine IV as prescribed by the physician.
The xray results come back and he has a complete fractured tibia. He is admitted to the medical/surgical unit and scheduled for surgery tomorrow. Report given to RN Mary on the medical/surgical unit.
Case Study for SOAPIER Note
RUBRIC |
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Excellent Quality 95-100%
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Introduction
45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Literature Support 91-84 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met. |
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Average Score 50-85% |
40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided. |
83-76 points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration. |
52-49 points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met. |
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Poor Quality 0-45% |
37-1 points The background and/or significance are missing. No search history information is provided. |
75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration. |
48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met |
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Case Study for SOAPIER Note |
Case Study for SOAPIER Note