Diagnostic Reasoning for Nurse Practitioners Clinical Note Guidelines Paper

Diagnostic Reasoning for Nurse Practitioners Clinical Note Guidelines Paper

Wilkes University

Passan School of Nursing

NSG 550: Diagnostic Reasoning for Nurse Practitioners

 Clinical Note Guidelines

 Each student will complete a clinical note utilizing the framework of a comprehensive health history and physical examination.  The written assignment is documentation of the findings and should demonstrate application of course content and follow the criteria provided below.  This should be in a charting format and no longer than 3 pages, excluding a title and reference page.  Five points will be deducted for assignments longer than the stated criteria. APA not required so single spacing is allowed. Mastering succinctness of communication, both written and verbal of clinical reasoning, is critical to the process of becoming a nurse practitioner. Diagnostic Reasoning for Nurse Practitioners Clinical Note Guidelines Paper



Content  Grade Percentage
Choose a patient to perform the H and P; this person could be a family member or patient from your clinical practice.

Only use initials when identifying the patient.

Chief Complaint and History of Present Illness 5%
Past Medical and Surgical History 5%
Medications and Allergies 5 %
Family History 5%
Social History 5%
Review of Systems (include only subjective symptoms obtained from the health history –what did the patient say?) 15%
Physical Examination (include only objective findings determined by the physical examination you completed). 15%
Assessment and Plan (You can make one section with the Assessment/Plan or you can keep them as separate sections).

Provide all possible diagnoses based upon clinical decision making listing the one with the highest probability first. Diagnostic Reasoning for Nurse Practitioners Clinical Note Guidelines Paper

Provide comprehensive treatment plan and communicate clinical reasoning; utilize theory from NSG500, 550, 530, and 533. Provide clinical support/citations.

Provides  references of peer reviewed,  scholarly citations 5%
Total 100%

Criteria for this written assignment can be found on the next page. This information was introduced in NSG 500.

 History—Subjective Data


Age, gender, DOB


Reason for seeking care-patient’s own words






A-aggravating/associated factors

R-relieving factors

T-temporal factors


Medications, treatments


General health, surgeries, hospitalizations, illnesses, immunizations, medications, allergies, blood transfusions, emotional status/psychiatric history Diagnostic Reasoning for Nurse Practitioners Clinical Note Guidelines Paper

Personal History

Cultural background, marital status, occupation, economic resources, environment

Health Habits

Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins

Health Maintenance

Last PE; diagnostic tests (date, result, follow-up); self-exams (breast, genital, testicular); last Pap smear, mammogram

Family History

(Parents, siblings, children)

Cancer, DM, hypertension, heart disease, stroke




Fever, chills, malaise, fatigue/energy, night sweats, desired weight


Appetite, restrictions, vitamins, supplements

Skin, Hair, Nails

Rash, eruptions, itching, pigment changes

Head and Neck

Headaches, dizziness, head injuries, loss of consciousness


Blurring, double vision, visual changes, glasses, trauma, eye diseases Diagnostic Reasoning for Nurse Practitioners Clinical Note Guidelines Paper


Hearing loss, pain, discharge, vertigo, tinnitus


Congestion, nosebleeds, postnasal drip

Throat and Mouth

Hoarseness, sore throat, bleeding gums, ulcers, tooth problems


Indigestion, heartburn, vomiting, bowel regularity/changes


Tenderness, enlargement


Heat/cold intolerance, weight change, polydipsia, polyuria, hair changes, increased hat, glove, or shoe size



LMP, age at menarche, gravity, parity, menses (onset, regularity, duration, symptoms), sexual life (number of partners, satisfaction), contraception, menopause (age, symptoms) Diagnostic Reasoning for Nurse Practitioners Clinical Note Guidelines Paper


Puberty onset, erections, testicular pain, libido, infertility


Pain, tenderness, lumps, discharge

Chest and Lungs

Cough, sputum, shortness of breath, dyspnea on exertion, night sweats, exposure to TB


Chest pain, palpitations, number of pillows, edema, claudication, exercise tolerance


Anemia, easy bruising


Dysuria, flank pain, urgency, frequency, nocturia, hematuria, dribbling


Joint pain, heat swelling


Fainting, weakness, loss of coordination

Mental Status

Concentration, sleeping, eating, socialization, mood changes, suicidal thoughts

 Physical Examination—Objective Data


TPR, BP, Ht, Wt, BMI, Pulse Ox

General Appearance

Age, race, gender, posture and gait

Mental Status

Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality


Color, integrity, hygiene, turgor, hydration, edema, lesions, hair distribution and texture, nail texture, nail base angle


Scalp, temporal arteries, deformities


Trachea (position, tug), range of motion (ROM), carotid bruit, jugular venous distention (JVD), thyroid, lymph (head and neck)


Pupils (PERRLA), eyelids, conjunctivae, sclerae, EOMs (CN III, IV, VI), light reflex, visual fields, funduscopy (CN II), acuity (CN II), nystagmus


Deformities, lesions, discharge, otoscopy (canal, TM), hearing (Rinne, Weber, CN VIII)


Mucosa, septum, turbinates, discharge, sinus area swelling or tenderness

Mouth and Throat

Lips/teeth/gums, tongue (CN XII), mucosa, palates, tonsils, exudate, uvula, gag reflex (CN IX, X)


Shape, movement, respirations (rate, rhythm), expansion, accessory muscles, tactile fremitus, crepitus, percussion tone, excursion, auscultation (clear, wheeze, crackles, rhonchi, rubs)


Contour, symmetry, nipples, areolae, discharge, lumps/masses, lymph (axillary, supraclavicular, and infraclavicular)


PMI, lifts, thrills, rate, rhythm, S1, S2, splitting, gallops, rubs, murmurs, snaps

Blood Vessels

Cyanosis, clubbing, edema, peripheral pulses, skin, nails


Contour, symmetry, skin, bowel sounds, bruits, hum, liver span, liver border, tenderness, masses, spleen, kidneys, aortic pulsation, reflexes, percussion tone, costovertebral angle (CVA) tenderness, femoral pulses, lymph (inguinal)

Male Genitalia

Pubic hair, glans, penis, testis, scrotum, epididymis, urethral discharge, hernias

Female Genitalia

External lesions or discharge, Bartholin and Skene glands, urethra, vaginal walls, cervix (position, lesions, cervical motion tenderness), uterus, adnexa


Sacrococcygeal and perineal areas, anus, sphincter tone, rectal walls, masses, fecal occult blood test (FOBT)

Male: Prostate

Female: Rectovaginal septum, uterus


Posture, alignment, symmetry, joint heat/swelling/color, muscle tone, ROM, strength


CN II-XII, rapid alternating movements, finger-to-nose, sensation, vibration, stereognosis, motor system, gait, Romberg, deep tendon reflexes (DTRs), superficial reflexes

Cranial Nerves

I: Smell

II: Visual acuity, visual fields, funduscopy

III, IV, VI: Eyelid opening EOMs: IV up and out, VI lateral, III all others

V: Corneal reflex, facial sensation (3 areas), jaw opening, bite strength

VII: Eyebrow raise, eyelid close, smile, taste

VIII: Rinne, Weber

IX, X: Gag reflex, palate elevation, phonation

XI: Lateral head rotation, neck flexion, shoulder shrug

XII: Tongue protrusion, lateral deviation strength


Diagnosis(es)-clinical reasoning


Treatment; rationale Diagnostic Reasoning for Nurse Practitioners Clinical Note Guidelines Paper

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