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assignment overview: Wellness is a broad concept. In this guide, we attempt to provide a broad, yet specific sense of what it means. We invite you to think of wellness as meaning being healthy in many dimensions of our lives. That includes the emotional, physical, occupational, intellectual, financial, social, environmental, and spiritual parts. These dimensions are interconnected, one dimension building on another…When we worry about money (for example, debt or being able to afford what we need), we sometimes experience anxiety (emotional). This can lead to medical problems (physical), and trouble at work (occupational). When this happens, we may even question our own sense of meaning and purpose (spiritual). At the same time, when we are not working (occupational), we may lose opportunities to interact with others (social), and may not be able to afford the good food and medical care we need to stay well (physical). We may even need to move our home to a place that feels less safe and secure (environmental)” (SAMHSA, n.d., p. 3). Read the ‘Creating a Healthier Life: A Step by Step Guide to Wellness’ Links to an external site. to learn more about the dimensions of wellness. ( ) This assignment will combine the Eight Dimensions of Wellness and how you prioritize tasks. Creating a Covey Matrix will help you visualize which everyday tasks and wellness items are most urgent and important in your life…and which ones are not. This is an effective tool for prioritizing and time management. In the next assignment, you will look more in-depth at the specific dimension of Occupational Wellness. Assignment Instructions: Consider each of the Eight Dimensions of Wellness and the exemplars within each dimension. Download the Covey Matrix template Download Covey Matrix template (I will provide template in attachment) and add each of the 20 exemplars to your template. Then analyze your results. Be clear and concise in your responses. Your submission should be 1-2 pages in length. 1. Consider where you placed the exemplars. Discuss item(s) that you previously thought were ‘important or urgent’, but, ultimately, were categorized as ‘less urgent or important’. 2. What can you delegate to someone else? How can you ease your load to be able to focus on ‘urgent/important’ tasks? 3. What items did you identify as ‘time-wasters’ or tasks that distract you (‘not urgent/not important’)? What is your strategy to reduce or eliminate these items? 4. For tasks you prioritized as ‘urgent/important’, what is your plan to ensure they are all completed on time? Eight Dimensions of Wellness and Exemplars:Covey Matrix Example: image.png image.png

Directions: Students may use this general SOAP note template or their own. Save a copy to your device to alter the document. Use APA when called for by the rubric or assignment prompt. The APA title page will be the first page, and the template will start on the second page. End with your APA formatted references. Keep in mind this template is structured for an average, problem-focused visit. This template will not be adequate for some special populations and situations (newborns/pregnancy visits/child wellness, etc.). Students need to use good clinical judgment and make additional headings and sections when needed and remove others as applies.

Consider viewing the EMS documentation guidelines from the US Department of Health and Human Services/CMS:

Delete all text in red – these are instructions and not part of the SOAP document.

Student Name and clinical course: (If no title page):______________________

ID:

Clients Initials*:_______Age_____ Race__________Gender____________Date of Birth___________

Insurance _______________ Marital Status_____________

*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect client confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.

Subjective:

CC: A few words, a sentence or less. Indicate who provided information about the symptoms. Example: Patient reported that Ive had a cough and sore throat for 2 days

HPI:

In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.

Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.

Medications: include name, dose, frequency, and route. Include PRN medications and how often they are taken.

Past Medical History:

Medical problem list: details on past and present illnesses, be careful not to blindly copy from prior clinical notes

Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)

Surgeries: past surgeries and rough dates when possible

Hospitalizations: past hospitalizations with reason for admit, duration of stay, and rough dates

LMP, pregnancy status, menopause, etc. for women

Allergies:

Food, drug, environmental: list medications and food allergies, specify type of reaction

Family History: go back 2 generation indicate if alive, deceased, or unknown. details on family members, their age, and illnesses/conditions.

Social History:

-Sexual history and contraception/protection (as applies to the case)

-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)

ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include diagnoses – those belong in PMH. Include only subjective data which patient reports or denies. Do not include any objective data which should go under physical examination. The below categories are per CMS guidelines.

Constitutional:

Eyes:

Ears/Nose/Mouth/Throat:

Cardiovascular:

Pulmonary:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary & breast:

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective

Vital Signs: HR BP Temp RR SpO2 Pain

Height Weight BMI (be sure to include percentiles for peds)

Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today

Physical Exam (write out by system):

Start with a General survey:

Skin:

HEENT (Head, Eyes, Ears, Nose, Throat):

Neck:

Cardiovascular (Heart):

Respiratory (Lungs):

Abdomen:

Back:

Rectal:

Extremities:

Musculoskeletal:

Neurologic:

Psychiatric:

Pelvic:

Breast:

Genitourinary (G/U):

Assessment

(you will often have more than one diagnosis/problem, but do the differential on the main problem, Support diagnoses with evidence-based references.)

Differentials (with a brief rationale for each):

1.

2.

3.

Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies)

Plan (4 pronged plan for each problem on the problem list, Support plans with national guidelines or evidence-based references.)

Diagnostics:

Treatment:

Education

Follow Up:

Reference