Nursing Homework week 11

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications: (including OTC and vitamins)

·

PMH:

Immunizations:

Preventive Care: Preventive Screenings: (for results already obtained before this encounter) - Pap smear: ______ - Mammogram: ______ - Colonoscopy: ______ - Lipid panel: ______ - A1C: ______ - STI screen: ______ - Depression screen (PHQ-9): ______

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

SUBJECTIVE DATE

Chief Complaint (which must be stated between “__”)

Symptom analysis/HPI:

Clinical Tools Used (if applicable), otherwise state N/A - PHQ-9: ___ /27 - GAD-7: ___ /21 - AUDIT-C / DAST:

Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states...”)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

OBJECTIVE DATA

VITAL SIGNS: LABS / DIAGNOSTICS REVIEWED (if available): - CBC: - Lipid Panel: - A1C: - EKG: - Imaging (if done):

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT

Red Flags / Reasons for Escalation: - [ ] None noted - [ ] Positive suicidal ideation - [ ] Unstable vital signs - [ ] Abnormal exam requiring urgent referral

Clinical Note

(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)

Example: “Pt came into our clinic today c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… On examination I noted erythema in the ear canal…, this, and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3) along with the rationale behind them. (why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)

-

-

-

PLAN

Labs and Diagnostic Test to be ordered (if applicable)

· -

· -

Pharmacological treatment:

-

Non-Pharmacologic treatment:

Education (provide the most relevant ones - tailored to this specific patient – not in general)

Follow-ups/Referrals

Visit Complexity / CPT Code: _______

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications: (including OTC and vitamins)

·

PMH:

Immunizations:

Preventive Care: Preventive Screenings: (for results already obtained before this encounter) - Pap smear: ______ - Mammogram: ______ - Colonoscopy: ______ - Lipid panel: ______ - A1C: ______ - STI screen: ______ - Depression screen (PHQ-9): ______

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

SUBJECTIVE DATE

Chief Complaint (which must be stated between “__”)

Symptom analysis/HPI:

Clinical Tools Used (if applicable), otherwise state N/A - PHQ-9: ___ /27 - GAD-7: ___ /21 - AUDIT-C / DAST:

Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states...”)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

OBJECTIVE DATA

VITAL SIGNS: LABS / DIAGNOSTICS REVIEWED (if available): - CBC: - Lipid Panel: - A1C: - EKG: - Imaging (if done):

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT

Red Flags / Reasons for Escalation: - [ ] None noted - [ ] Positive suicidal ideation - [ ] Unstable vital signs - [ ] Abnormal exam requiring urgent referral

Clinical Note

(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)

Example: “Pt came into our clinic today c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… On examination I noted erythema in the ear canal…, this, and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3) along with the rationale behind them. (why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)

-

-

-

PLAN

Labs and Diagnostic Test to be ordered (if applicable)

· -

· -

Pharmacological treatment:

-

Non-Pharmacologic treatment:

Education (provide the most relevant ones - tailored to this specific patient – not in general)

Follow-ups/Referrals

Visit Complexity / CPT Code: _______

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).