Follow these guidelines for APA. This is maternity note ,please adapt to advance primary care

Follow these guidelines for APA. This is maternity note ,please adapt to advance primary care

References in APA have to be within a 5-year range.

Make sure you include Psych History as well and also Genitourinary system.

 

Semester:

SpringCourse:MSN5700C Advanced Practice in Primary Care IPreceptor:ARENCIBIA, ALEXEISClinical Site:AMERICAN CARE (SOUTH TAMPA)Setting Type:

Patient Demographics

Age:

74 years

Race:

Black or African American

Gender:

Male

Insurance:

Medicare

Referral:

Nutritionist

Clinical Information

Time with Patient:

40 minutes

Consult with Preceptor:

15 minutesType of Decision-Making:Moderate complexityReason for Visit:Follow-up (Routine)Chief Complaint:HTN follow upType of HP:ComprehensiveSocial Problems Addressed:Emotional
Prevention
Nutrition/Exercise
Substance Abuse
Procedures/Skills (Observed/Assisted/Performed)

Physical Assessment – Physical Assessment (Perf)
General Skills – EKG (Perf)
General Skills – Vital Signs (Perf)
ICD-10 Diagnosis Codes#1 – I10 – ESSENTIAL (PRIMARY) HYPERTENSION#2 – E66.9 – OBESITY, UNSPECIF

Medications

# OTC Drugs taken regularly:

1# Prescriptions currently prescribed:2# New/Refilled Prescriptions This Visit:1Types of New/Refilled Prescriptions This Visit:
Cardiology – Antilipids
Cardiology – Calcium channel blockers
Adherence Issues with Medications:
Caretaker failure
Financial concerns
Forgetfulness
Other Questions About This Case

Patient’s Primary Language:EnglishSmoking Assessment:HistoryAdvanced Directive:Yes, on file

Packs per day:

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    SOAPNOTEMATERNITY003.docx
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    SoapAllergicRinitis.docx