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