Note: I attached the instructions. The paper does specify exact number of citation. Would you please use atleast 3 or 4 citations.
Clinical DecisionMaking (CDM) Paper
TIPS FOR DEVELOPING YOUR CDM: (4-5 pages max [not includingreferences]- so be specific) Asthma CDM.pdf
1. It is not necessary to do a comprehensivereview of systems (ROS), but pertinent systems must be included for theepisodic visit. However, include General, Respiratory, Cardiovascular,and Abdominal ROSs should be completed on all patients. You should completea ROS with information pertinent to the presenting problem, current medications(indicate why patient is taking the medication, i.e.,Amoxicillin 250 mg po bid for otitis media, etc.), and status of concurrenthealth problems only. Pertinent past medical history, family history, andsocial history should be addressed. Your history should be focused.
2. If there is additional information you want toknow that is pertinent to the diagnosis, that is not present in the writtencase, write these as questions you would ask and/or additional examinations(assessments) you would perform. Please make sure to write questions as youwould ask the parent(s)/child (i.e., non-technical terms). It issuggested that you put questions in italics, so they can be easily found. Thesequestions/further assessments should be in the appropriate areas of thesubjective and/or objective information.
3. When you are doing your review of systems, thegeneral category includes symptoms (subjective) such as fever, malaise,fatigue, night sweats, and weight change. It does not include any objectiveinformation such as alert, oriented, or good historian.
4. If you have a positive complaint,it must be addressed in the physical exam, assessment, and plan.
5. On your diagnosis, please make sure to lookfor and chart if the patient has more than one diagnosis. This is possible.
6. Rule out diagnoses are those diagnoses thatyou are waiting for further test results. Your patient may or may not have arule out diagnosis. A differential diagnosis is merely one that you consideras you are taking the history, and doing the physical exam. You should haveseveral. It is not addressed in the plan, as it is not one of your mostlikely.
7. Use multiple sources as you reference thepathophysiology. Please note that you must providepathophysiology and relate it to your patient! Make sure that youre-word and cite your source/s for the pathophysiology. As a reminder, morethan five words in a row should have quotations (See APA).
8. Use National Guidelines to develop your planand rationale for the management portion. All sources must be referencedaccording to APA format. It is required thatyou check websites ( National Heart Lung and Blood Institute [NHLBI], NationalInstitutes of Health [NIH], etc.) for the latest practice guideline, pleasemake sure to use it.
9. Some examples of websites for guidelines include:
11. When you are giving the rationale formedication usage, please explain the drugs category and action (i.e., thirdgeneration cephalosporin antibiotic and is used primarily for gram positiveorganisms), and why the patient has been prescribed the particular medication.
12. Include all references used throughout in APAformat. This includes references used for your subjective questions/information.
A. Chief complaint.
B. History of Present Illness with 7variables (write in 7 variables) as used in the UT Arlington AdvancedAssessment Course (N5418).
The present illness should include all positive historicalfindings, as well as pertinent negatives, regardless of where in the historythe information normally would be placed. For example, the immunization historyshould be mentioned here for a patient suspected of having measles, even thoughimmunizations usually are mentioned in the past history. Similarly, a familyhistory of sickle cell anemia should be mentioned in a patient admitted forevaluation of anemia, even though it usually is discussed in the familyhistory.
Remember physical examinations, laboratory evaluations,assessments, and treatments that occurred before this presentation are now partof the history and should be included now, at the appropriate chronologicalpoint in the history. Avoid giving your assessment at this point; this belongslater, in the assessment section.
1. Current medications
3. Last physical examinations
4. Immunization status
5. Past Medical History
6. Illnesses / trauma
8. Emotional/Psychiatric History
9. Family History
10. Personal/Social History
11. Review of Systems (appropriate to clinical scenario);all patients should include General, Respiratory, Cardiovascular, andAbdominal, regardless of the complaint.
Examination of appropriate systems, laboratoryor diagnostic test (if results are available.)
Be sure to includegrowth percentiles and BMI (as appropriate to age)
B. Diagnosis(es) ICD 10 Codes with pathophysiologythat correlates with the
C. patient data for major diagnosis. Includereferences. This is not to be an
D. excerpt from a medical text, rather arationale for choosing this diagnosis
E. that is related back to your patient. You needto list pertinent positives (why you think what you think). At
F. times, a secondary diagnosis may also be present(please watch out for this!). If
G. you have more than one diagnosis,pathophysiology must be supplied for EACH diagnosis.
B. Differential Diagnoses this may be alaundry list of ALL possiblediagnosis that could fit the data
you are given. List at least 2 differential diagnoses.
A. Write a plan of care for the patient describedin the case. Include a detailed, scientific, evidence-based rationalefor each intervention you plan. Search the current literature and finda national guideline to guide your management plan (may be provided for you inyour reading). If you plan a new, controversial, or not widely usedintervention, provide specific references and a discussion of the literaturesupporting the use of the intervention. If you noted something duringthe Subjective or Objective part of the history and physical (H&P), youhave to mention it in your plan.
B. Cost Effectiveness of your Plan please discussthe cost effectiveness, pricing for medications, formula changes, labs, orother testing, etc. It is also suggested you include the officevisit, etc. You should list actual costs you have researched (and cite thesources).
C. Diagnostic studies and/or laboratory tests withrationale for each treatment in the management plan and appropriate references.The plan should include how you will rule-out or rule-in your primarydiagnosis and each of the diagnosis listed.
D. Medical therapeutics/Nursing therapeutics,prescriptions with rationale for each treatment and appropriate references.
E. Patient education with references
F. Counseling (when appropriate)
G. Health promotion/health maintenance (Thisis NOT patient education related to thediagnosis; this is information to keep your patient safe and well.)
H. Referral(s) (when appropriate)
I. Consult(s) (when appropriate)
J. Follow-up appointments
2. FormalClinical Decision Making (CDM) Assignment Rubric (1)
Formal Clinical Decision Making (CDM) Assignment Rubric (1)
This criterion is linked to a Learning OutcomeSubjective and Objective Database
20 to >0.0 pts
Completed subjective and objective database, as appropriate to scenario. 7 variables (5 points) – 2 points if not put into 7 variables PMH (2 points), FH (2 points), SH (1 point) ROS (3 points) Objective (5 points) – Growth percentiles (1 point out of the 5 points for objective); points will be taken off if percentiles incorrect – BMI (1 point out of the 5 points for objective); points will be taken off if BMI incorrect or BMI is done when it should not be (age appropriate) Additional questions written that would be asked (not provided in scenario) (2 points)
This criterion is linked to a Learning OutcomeData, Assessment, Diagnoses
20 to >0.0 pts
Data prioritized, with pertinent positives established. Assessments, rule-out diagnoses, and differential diagnoses stated appropriately with the ICD-10 Code(s). ICD-10 codes should be referenced. Pertinent positives (2 points) Diagnosis/diagnoses include all diagnoses (10 points) Rule-out, if applicable (1 point) Differentials (4 points; 2 points each) ICD-10 codes (3 points)
This criterion is linked to a Learning OutcomePathophysiology
20 to >0.0 pts
Physiological and pathological (patho) process leading to diagnosis(es) are documented and referenced. Patho must be completed on EACH main diagnosis. Includes judgment and references (10 points) Must relate to patient (10 points)
This criterion is linked to a Learning OutcomePlan, Cost-Effectiveness, Health Promotion/Maintenance
20 to >0.0 pts
Plan is sound, logical, cost-effective includes both medical(per AAP guideline) and nursing management and is referenced. Should put initial tests that are indicated order these tests first and if additional tests are required, briefly discuss what might be needed at a later time or visit. Should include a section entitled Health Promotion/Health Maintenance. Make sure to include ALL sections listed in the template. Plan (12 points) Cost effectiveness (4 points) Health Promotion/Health Maintenance (4 points) Missing Asthma Action plan (prior submission) -5
This criterion is linked to a Learning OutcomeRationale, References, Grammar and Spelling
20 to >0.0 pts
Rationale and references are provided for each step in the management plan. An appropriate National Guideline should be used and referenced in your plan. Additionally, grammar and spelling should be appropriate. Rationale (5 points) References in CDM and plan (5 points) National Guideline used (5 points) Spelling/grammar (5 points) * Points may be taken off if template provided not used
Total Points: 100
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