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.
Content Grade Percentage
Choose a patient to perform the H and P; this person could 5%
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 (subjective-complete review of systems 15%
including pertinent positive and negative findings as per
the patient-what did the patient say)
Physical Examination (objective-complete PE including 15%
pertinent positive and negative PE findings).
Assessment and Plan (You can make one section with 35%
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.
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
ID
Age, gender, DOB
CC
Reason for seeking care-patient’s own words
HPI
O-onset
L-location
D-duration
C-character
A-aggravating/associated factors
R-relieving factors
T-temporal factors
S-severity
Medications, treatments
PMH/PSH
General health, surgeries, hospitalizations, illnesses, immunizations, medications, allergies, blood
transfusions, emotional status/psychiatric history
Personal History
Cultural background, marital status, occupation, economic resources, environment
Health Habits
Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins
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.
Content Grade Percentage
Choose a patient to perform the H and P; this person could 5%
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 (subjective-complete review of systems 15%
including pertinent positive and negative findings as per
the patient-what did the patient say)
Physical Examination (objective-complete PE including 15%
pertinent positive and negative PE findings).
Assessment and Plan (You can make one section with 35%
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.
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
ID
Age, gender, DOB
CC
Reason for seeking care-patient’s own words
HPI
O-onset
L-location
D-duration
C-character
A-aggravating/associated factors
R-relieving factors
T-temporal factors
S-severity
Medications, treatments
PMH/PSH
General health, surgeries, hospitalizations, illnesses, immunizations, medications, allergies, blood
transfusions, emotional status/psychiatric history
Personal History
Cultural background, marital status, occupation, economic resources, environment
Health Habits
Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins
