56-year-old female patient: Patient initials are E T

56-year-old female patient: Patient initials are E T

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56-year-old female patient: Patient initials are E T

CC: To go over gensight test, Not sleeping well at night, complaints of anxiety, feels she suffers from bipolar

Meds: Hysocomine, 0.125 PO PRN daily SL

Losartan Potassium 100 MG tabs

Isosorbride Mononit ER 30 MG TB

Estradiol 0.5 MG Tabs

Topiramate 100 MG Tabs

Atorvastatin 10 MG Tablet

Flovent HFA 44 MCG/ACT

CETIRIZINE HCL 10 MG/ACT

ESTRACE 0.1 MG/GM CREA

VITAMIN D 1.25 MG (50000 UT) CAPS

Patient wellbeing: Patient is very emotional, worried and tearful, during assessment. Was very cooperative during the interview, smile throughout, patient has financial stress, personal illness and economic. Patient has poor sense of, course is expected to be chronic, because patient is hard to treat.

Psych syndrome: depression, anxiety loss of pleasure of usual activities, headaches, light headaches, decrease exercise, feeling of hopeless. Depression, anxiety, loss of pressure in usual activities and feeling hopeless., headaches, light headache, abdominal pain, nausea, constipation, changes in stool, wt loss, changes in stool sizes.

Skin Comprehensive SOAP Note

 Patient Initials: _______                     Age: ______                           Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

 

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:.

Musculoskeletal:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Mental examination:

Diagnostic result:

Patient education:

Treatment:

.

Diagnostic results:

Clubbing-

Radiology:

CXR :

ECG:

Normal sinus rhythmic movement:

Spirometry-

ASSESSMENT:

Differential Diagnosis (DDx):

Primary Diagnoses:

PLAN:

 

 

Patient

14F: CC: F/U feels the same, but more energetic

Meds: Pristiq 50mg, Vistaril 50mg

Dx: depression, anxiety, ADHD

Change: none

Learning Resources

Required Readings (click to expand/reduce)

 

American Academy of Child and Adolescent Psychiatry. (2018). CPT code training module. https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/business_of_practice/cpt/2018_CPT_module_revised_March_2018.pdf

American Association of Nurse Practitioners. (2019). Discussion paper: Standards of practice for nurse practitioners. https://storage.aanp.org/www/documents/advocacy/position-papers/StandardsOfPractice.pdf

American Psychiatric Association. (2020). Coding and reimbursement. https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/coding-and-reimbursement

American Psychiatric Nurses Association. (2013). Population-focused nurse practitioner competencies. https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/Competencies/CompilationPopFocusComps2013.pdf

Note: Review the Psychiatric Mental Health Nurse Practitioner Competencies.

HSoft Corporation. (2020). Meditrek: Home. https://edu.meditrek.com/Default.html   

Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.  

International Council of Nurses. (2020). Guidelines on advanced practice nursing 2020. Author. https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf

The National Organization of Nurse Practitioner Faculties. (n.d.). Retrieved August 24, 2020, from https://www.nonpf.org/

The National Organization of Nurse Practitioner Faculties. (2017). Nurse practitioner core competencies content. https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/competencies/20170516_NPCoreCompsContentF.pdf

Walden University Academic Skills Center. (2017). Developing SMART goals. https://academicguides.waldenu.edu/ld.php?content_id=51901492

Walden University. (2020). College of Nursing practicum manual: Master of science in nursing (MSN) and post-master’s certificate programs. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments

Walden University Field Experience. (2020a). Field experience: College of Nursing.  https://academicguides.waldenu.edu/fieldexperience/son/home 

 

The patient log must include the following:

  • Date
  • Course
  • Clinical Faculty
  • Preceptor
  • Patient Number
  • Client Information
  • Visit Information
  • Practice Management
  • Diagnosis
  • Student Notes- Students must include a brief summary/synopsis of the patient visit—this does not need to be a SOAP note; however, the note needs to be sufficient to remember your patient encounter

 

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