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Category: Nursing

  • [Solved] Fall

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    Please see attached. Due: 4/22-4/23 (ASAP) 1 – 2 pages. Times New Roman 12-point font, double-spaced – 2 years ago **files (1)** – ## Fall.docx **## Fall.docx** Discussion Prompt Mr. Jones is a 67 year old male that is accompanied by his wife to your clinic. He is following up after an ER visit for …

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    Assignment Prompt & Instructions

    Please see attached.

    Due: 4/22-4/23 (ASAP)

    1 – 2 pages. Times New Roman 12-point font, double-spaced

    – 2 years ago

    **files (1)**

    – ## Fall.docx

    **## Fall.docx**

    Discussion Prompt

    Mr. Jones is a 67 year old male that is accompanied by his wife to your clinic. He is following up after an ER visit for a fall at home that resulted in 6 stitches to his forehead. His CT of the brain was negative during his emergency department visit and his sutures were removed 5 days following the visit. He has no other complaints other than was told by the ER to follow up with his primary care, and admits it has been a little while, several years, since he has been in to see his primary care provider. He admits that he had a few drinks that night before tripping over his dog. His wife adds that he has "a few drinks" every night.

    How will you proceed with Mr. Jones? What diagnostics and screening will you perform? What will potentially be part of your treatment plan? What specific resources in your own community (city or region) will you refer him to?
    Utilize high-level scholarly resources and links to specific regional resources to support your discussion. Avoid point-of-care references.

    In addition to answering the questions above, remember it has been a few years since his last visit to see a primary care provider, so also mention a complete physical including labs and screenings that the provider should recommend for him at this time.

    **## Fall.docx**

    Discussion Prompt

    Mr. Jones is a 67 year old male that is accompanied by his wife to your clinic. He is following up after an ER visit for a fall at home that resulted in 6 stitches to his forehead. His CT of the brain was negative during his emergency department visit and his sutures were removed 5 days following the visit. He has no other complaints other than was told by the ER to follow up with his primary care, and admits it has been a little while, several years, since he has been in to see his primary care provider. He admits that he had a few drinks that night before tripping over his dog. His wife adds that he has "a few drinks" every night.

    How will you proceed with Mr. Jones? What diagnostics and screening will you perform? What will potentially be part of your treatment plan? What specific resources in your own community (city or region) will you refer him to?
    Utilize high-level scholarly resources and links to specific regional resources to support your discussion. Avoid point-of-care references.

    In addition to answering the questions above, remember it has been a few years since his last visit to see a primary care provider, so also mention a complete physical including labs and screenings that the provider should recommend for him at this time.

  • [Solved] Note

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  • [Solved] Discussion Post

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    In-depth study guidance and analytical solution covering Discussion Post.

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  • [Solved] Nursing

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    legislative agenda Review the Personal Legislative Agenda and Action Plan Exemplar to demonstrate how you will construct your Personal Legislative Agenda for the state and federal proposed legislation. Review the Personal Legislative Agenda and Action Plan Exemplar to determine which approach might …

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    legislative agenda

    Review the Personal Legislative Agenda and Action Plan Exemplar to demonstrate how you will construct your Personal Legislative Agenda for the state and federal proposed legislation.

    Review the Personal Legislative Agenda and Action Plan Exemplar to determine which approach might work best for advancing your policy initiatives at various stages of the legislative process. Submit a Personal Legislative Agenda detailing your strategy for moving your policy through the legislative process, using the Personal Legislative and Agenda and Action Plan Exemplar as your template.

    In your Personal Legislative Agenda, choose from the strategies provided in Advocacy Toolkit resource that best suite moving your policies forward. Be sure to connect the strategies to the appropriate sections of the policy model you selected in Module 2.

    – 2 years ago

  • [Solved] week 15

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    read the outline and use the attached pdf to write it – 2 years ago

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    Assignment Prompt & Instructions

    read the outline and use the attached pdf to write it

    – 2 years ago

  • [Solved] cl

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  • [Solved] soap note

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    read what is attached and soap note will be om a 15 year old who has bipolar and scjizophernia – 2 years ago **files (2)** – ## soapnoteinstructions.docx – ## soapnotetemplatetouse.docx **## soapnoteinstructions.docx** 1. Compose a written comprehensive psychiatric evaluation of a patient you have …

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    read what is attached  and soap note will be om a 15 year old who has bipolar and scjizophernia

    – 2 years ago

    **files (2)**

    – ## soapnoteinstructions.docx

    – ## soapnotetemplatetouse.docx

    **## soapnoteinstructions.docx**

    1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.

    2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.

    ·
    **For the Comprehensive Psychiatric Evaluation Presentation Assignment:** You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).

    **Step 2:** Each student will create a focused SOAP note video presentation in the next assignment. See
    [Comprehensive Psychiatric Evaluation Presentation 1](https://stu.instructure.com/courses/43967/assignments/579648?wrap=1) for more details.

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.

    **S =**

    Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS)

    **O =**

    Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam

    **A =**

    Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes

    **P =**

    Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up

    **Other:** Incorporate current clinical guidelines
    [NIH Clinical GuidelinesLinks to an external site.](https://www.nccih.nih.gov/health/providers/clinicalpractice) or
    [APA Clinical GuidelinesLinks to an external site.](https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines), research articles, and the role of the PMHNP in your evaluation.

    atatched is the soap note template use apa 7 the dition

    **## soapnotetemplatetouse.docx**

    **Psychiatric SOAP Note Template**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems:**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    ****Significant Data/Contributing Dx/Labs/Misc.****

    ****Plan:****

    ****Differential Diagnoses****

    ****1.****

    ****2.****

    ****Principal Diagnoses****

    ****1.****

    ****2.****

    ****Plan****

    ****Diagnosis #1****

    ****Diagnostic Testing/Screening:****

    ****Pharmacological Treatment:****

    ****Non-Pharmacological Treatment:****

    ****Education:****

    ****Referrals:****

    ****Follow-up:****

    ****Anticipatory Guidance:****

    ****Diagnosis #2****

    ****Diagnostic Testingg/Screenin:****

    ****Pharmacological Treatment:****

    ****Non-Pharmacological Treatment:****

    ****Education:****

    ****Referrals:****

    ****Follow-up:****

    ****Anticipatory Guidance:****

    ****Signature (with appropriate credentials): __________________________________________****

    ****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****

    ****DEA#: 101010101 STU Clinic LIC# 10000000****

    ****Tel: (000) 555-1234 FAX: (000) 555-12222****

    **Patient Name: (Initials)______________________________ Age ___________**

    **Date: _______________**

    ****RX ______________________________________****

    ****SIG:****

    ****Dispense**: ___________**
    ****Refill:** _________________**

    ****No Substitution****

    ****Signature:** ____________________________________________________________**

    ****Rev. 10162021 LM****

    **## soapnotetemplatetouse.docx**

    **Psychiatric SOAP Note Template**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems:**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    ****Significant Data/Contributing Dx/Labs/Misc.****

    ****Plan:****

    ****Differential Diagnoses****

    ****1.****

    ****2.****

    ****Principal Diagnoses****

    ****1.****

    ****2.****

    ****Plan****

    ****Diagnosis #1****

    ****Diagnostic Testing/Screening:****

    ****Pharmacological Treatment:****

    ****Non-Pharmacological Treatment:****

    ****Education:****

    ****Referrals:****

    ****Follow-up:****

    ****Anticipatory Guidance:****

    ****Diagnosis #2****

    ****Diagnostic Testingg/Screenin:****

    ****Pharmacological Treatment:****

    ****Non-Pharmacological Treatment:****

    ****Education:****

    ****Referrals:****

    ****Follow-up:****

    ****Anticipatory Guidance:****

    ****Signature (with appropriate credentials): __________________________________________****

    ****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****

    ****DEA#: 101010101 STU Clinic LIC# 10000000****

    ****Tel: (000) 555-1234 FAX: (000) 555-12222****

    **Patient Name: (Initials)______________________________ Age ___________**

    **Date: _______________**

    ****RX ______________________________________****

    ****SIG:****

    ****Dispense**: ___________**
    ****Refill:** _________________**

    ****No Substitution****

    ****Signature:** ____________________________________________________________**

    ****Rev. 10162021 LM****

    **## soapnoteinstructions.docx**

    1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.

    2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.

    ·
    **For the Comprehensive Psychiatric Evaluation Presentation Assignment:** You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).

    **Step 2:** Each student will create a focused SOAP note video presentation in the next assignment. See
    [Comprehensive Psychiatric Evaluation Presentation 1](https://stu.instructure.com/courses/43967/assignments/579648?wrap=1) for more details.

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.

    **S =**

    Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS)

    **O =**

    Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam

    **A =**

    Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes

    **P =**

    Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up

    **Other:** Incorporate current clinical guidelines
    [NIH Clinical GuidelinesLinks to an external site.](https://www.nccih.nih.gov/health/providers/clinicalpractice) or
    [APA Clinical GuidelinesLinks to an external site.](https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines), research articles, and the role of the PMHNP in your evaluation.

    atatched is the soap note template use apa 7 the dition

    **## soapnotetemplatetouse.docx**

    **Psychiatric SOAP Note Template**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems:**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    ****Significant Data/Contributing Dx/Labs/Misc.****

    ****Plan:****

    ****Differential Diagnoses****

    ****1.****

    ****2.****

    ****Principal Diagnoses****

    ****1.****

    ****2.****

    ****Plan****

    ****Diagnosis #1****

    ****Diagnostic Testing/Screening:****

    ****Pharmacological Treatment:****

    ****Non-Pharmacological Treatment:****

    ****Education:****

    ****Referrals:****

    ****Follow-up:****

    ****Anticipatory Guidance:****

    ****Diagnosis #2****

    ****Diagnostic Testingg/Screenin:****

    ****Pharmacological Treatment:****

    ****Non-Pharmacological Treatment:****

    ****Education:****

    ****Referrals:****

    ****Follow-up:****

    ****Anticipatory Guidance:****

    ****Signature (with appropriate credentials): __________________________________________****

    ****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****

    ****DEA#: 101010101 STU Clinic LIC# 10000000****

    ****Tel: (000) 555-1234 FAX: (000) 555-12222****

    **Patient Name: (Initials)______________________________ Age ___________**

    **Date: _______________**

    ****RX ______________________________________****

    ****SIG:****

    ****Dispense**: ___________**
    ****Refill:** _________________**

    ****No Substitution****

    ****Signature:** ____________________________________________________________**

    ****Rev. 10162021 LM****

    **## soapnoteinstructions.docx**

    1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.

    2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.

    ·
    **For the Comprehensive Psychiatric Evaluation Presentation Assignment:** You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).

    **Step 2:** Each student will create a focused SOAP note video presentation in the next assignment. See
    [Comprehensive Psychiatric Evaluation Presentation 1](https://stu.instructure.com/courses/43967/assignments/579648?wrap=1) for more details.

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.

    **S =**

    Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS)

    **O =**

    Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam

    **A =**

    Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes

    **P =**

    Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up

    **Other:** Incorporate current clinical guidelines
    [NIH Clinical GuidelinesLinks to an external site.](https://www.nccih.nih.gov/health/providers/clinicalpractice) or
    [APA Clinical GuidelinesLinks to an external site.](https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines), research articles, and the role of the PMHNP in your evaluation.

    atatched is the soap note template use apa 7 the dition

    **## soapnotetemplatetouse.docx**

    **Psychiatric SOAP Note Template**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems:**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    ****Significant Data/Contributing Dx/Labs/Misc.****

    ****Plan:****

    ****Differential Diagnoses****

    ****1.****

    ****2.****

    ****Principal Diagnoses****

    ****1.****

    ****2.****

    ****Plan****

    ****Diagnosis #1****

    ****Diagnostic Testing/Screening:****

    ****Pharmacological Treatment:****

    ****Non-Pharmacological Treatment:****

    ****Education:****

    ****Referrals:****

    ****Follow-up:****

    ****Anticipatory Guidance:****

    ****Diagnosis #2****

    ****Diagnostic Testingg/Screenin:****

    ****Pharmacological Treatment:****

    ****Non-Pharmacological Treatment:****

    ****Education:****

    ****Referrals:****

    ****Follow-up:****

    ****Anticipatory Guidance:****

    ****Signature (with appropriate credentials): __________________________________________****

    ****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****

    ****DEA#: 101010101 STU Clinic LIC# 10000000****

    ****Tel: (000) 555-1234 FAX: (000) 555-12222****

    **Patient Name: (Initials)______________________________ Age ___________**

    **Date: _______________**

    ****RX ______________________________________****

    ****SIG:****

    ****Dispense**: ___________**
    ****Refill:** _________________**

    ****No Substitution****

    ****Signature:** ____________________________________________________________**

    ****Rev. 10162021 LM****

  • [Solved] WK3 ASSIGNMENT HP-114

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    COMPLETE WORK IN DETAIL – 2 years ago **files (1)** – ## WK3ASSIGNMENTHP-114.docx **## WK3ASSIGNMENTHP-114.docx** **Exploring the Skeletal and Muscular Systems** This assignment is designed to enhance your understanding of the intricate language used to describe the structures, functions, and disord…

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    COMPLETE WORK IN DETAIL

    – 2 years ago

    **files (1)**

    – ## WK3ASSIGNMENTHP-114.docx

    **## WK3ASSIGNMENTHP-114.docx**

    **Exploring the Skeletal and Muscular Systems**

    This assignment is designed to enhance your understanding of the intricate language used to describe the structures, functions, and disorders related to these crucial components of the human body.

    **Assignment Instructions**

    Explore the medical terms related to the Skeletal and Muscular Systems. Identify and define key terms, including bones, muscles, and relevant anatomical features.

    Anatomy Terminology Breakdown (Skeletal System):

    · Choose 10 terms related to the skeletal system.

    · Break down each term into its root, prefix, and suffix.

    · Provide definitions for each component and explain how they contribute to the term's meaning.

    Anatomy Terminology Breakdown (Muscular System):

    · Choose 10 terms related to the muscular system.

    · Break down each term into its root, prefix, and suffix.

    · Provide definitions for each component and elucidate their significance in conveying the term's meaning.

    Functionality and Physiology:

    · Discuss the physiological aspects of the Skeletal and Muscular Systems.

    · Explain how these systems collaborate to facilitate movement, support, and overall body functionality.

    Clinical Application:

    · Investigate a clinical condition or disorder associated with either the Skeletal or Muscular System.

    · Provide a brief overview of the condition, including its symptoms and potential treatments.

    · Analyze the medical terminology used to describe the condition. 200 WORDS

    **## WK3ASSIGNMENTHP-114.docx**

    **Exploring the Skeletal and Muscular Systems**

    This assignment is designed to enhance your understanding of the intricate language used to describe the structures, functions, and disorders related to these crucial components of the human body.

    **Assignment Instructions**

    Explore the medical terms related to the Skeletal and Muscular Systems. Identify and define key terms, including bones, muscles, and relevant anatomical features.

    Anatomy Terminology Breakdown (Skeletal System):

    · Choose 10 terms related to the skeletal system.

    · Break down each term into its root, prefix, and suffix.

    · Provide definitions for each component and explain how they contribute to the term's meaning.

    Anatomy Terminology Breakdown (Muscular System):

    · Choose 10 terms related to the muscular system.

    · Break down each term into its root, prefix, and suffix.

    · Provide definitions for each component and elucidate their significance in conveying the term's meaning.

    Functionality and Physiology:

    · Discuss the physiological aspects of the Skeletal and Muscular Systems.

    · Explain how these systems collaborate to facilitate movement, support, and overall body functionality.

    Clinical Application:

    · Investigate a clinical condition or disorder associated with either the Skeletal or Muscular System.

    · Provide a brief overview of the condition, including its symptoms and potential treatments.

    · Analyze the medical terminology used to describe the condition. 200 WORDS

  • [Solved] WK3 DISCUSSION2 HP-114

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    COMPLETE WORK IN DETAIL 250 WORDS – 2 years ago **files (1)** – ## WK3DISCUSSION2HP-114.docx **## WK3DISCUSSION2HP-114.docx** **Muscle and Bone: A Deeper Look** As you delve into the terminology specific to the Muscular and Skeletal systems, it is crucial to connect these words with tangible and rea…

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    Assignment Prompt & Instructions

    COMPLETE WORK IN DETAIL 250 WORDS

    – 2 years ago

    **files (1)**

    – ## WK3DISCUSSION2HP-114.docx

    **## WK3DISCUSSION2HP-114.docx**

    **Muscle and Bone: A Deeper Look**

    As you delve into the terminology specific to the Muscular and Skeletal systems, it is crucial to connect these words with tangible and real-world applications. Unlike the skin, the muscles and bones provide a dynamic framework for movement and support. You can feel your muscles at work during physical activities, and your bones create a sturdy foundation for your body.

    **Discussion Points**

    Summarize Key Functions:

    · Summarize 4-5 of the most important functions of the Muscular and Skeletal systems.

    · Utilize the proper medical terms associated with these functions.

    Understanding Physiology:

    · Explore and explain how these systems work physiologically to enable movement, support, and overall body functionality.

    · Provide insights into the intricate processes that contribute to the functionality of muscles and bones.

    Pathophysiology Exploration:

    · Discuss one way in which something can go wrong with either the Muscular or Skeletal system.

    · Highlight the impact of this dysfunction on the body's overall health and mobility.

    Peer Feedback:

    · Provide constructive feedback on your peers' posts, offering insights or additional information related to their discussions.

    200 WORDS

    **## WK3DISCUSSION2HP-114.docx**

    **Muscle and Bone: A Deeper Look**

    As you delve into the terminology specific to the Muscular and Skeletal systems, it is crucial to connect these words with tangible and real-world applications. Unlike the skin, the muscles and bones provide a dynamic framework for movement and support. You can feel your muscles at work during physical activities, and your bones create a sturdy foundation for your body.

    **Discussion Points**

    Summarize Key Functions:

    · Summarize 4-5 of the most important functions of the Muscular and Skeletal systems.

    · Utilize the proper medical terms associated with these functions.

    Understanding Physiology:

    · Explore and explain how these systems work physiologically to enable movement, support, and overall body functionality.

    · Provide insights into the intricate processes that contribute to the functionality of muscles and bones.

    Pathophysiology Exploration:

    · Discuss one way in which something can go wrong with either the Muscular or Skeletal system.

    · Highlight the impact of this dysfunction on the body's overall health and mobility.

    Peer Feedback:

    · Provide constructive feedback on your peers' posts, offering insights or additional information related to their discussions.

    200 WORDS

  • [Solved] WK3 DISCUSSION HP-114

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    COMPLETE WORK IN DETAIL. 250 WORDS – 2 years ago **files (1)** – ## hWK3DISCUSSION1HP-114.docx **## hWK3DISCUSSION1HP-114.docx** **he Secret Language of the Health Professions** Right about now you will likely be feeling a bit overwhelmed. If you are completely overwhelmed, you need to be communicat…

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    Assignment Prompt & Instructions

    COMPLETE WORK IN DETAIL. 250 WORDS

    – 2 years ago

    **files (1)**

    – ## hWK3DISCUSSION1HP-114.docx

    **## hWK3DISCUSSION1HP-114.docx**

    **he Secret Language of the Health Professions**

    Right about now you will likely be feeling a bit overwhelmed. If you are completely overwhelmed, you need to be communicating with your instructor so we can give you extra assistance to be certain you do not fall behind. Being a bit overwhelmed is normal. As you read through the text there are terms and content that seem much like a foreign language to you.

    Let’s give it a go – watch this video:
    [Easy German – Basic Conversation Phrases 1 (03:22)](https://www.youtube.com/watch?v=uO0jWxhVW1A%20)

    Clearly, learning German would take some time and practice. So does learning the language used in the health professions. But when you do learn it, this special language of ours can be rather fun. It makes us members of an exclusive club, the general public is not invited.

    It also poses great safety risks. If we do not learn the language properly, the risk of errors increases as we may get something wrong or be misunderstood by another health professional. If we are not careful the patient has no idea what is going on, or what they are supposed to do. Miscommunication has caused innumerable deaths, including that of infants whose parents did not understand the pharmacy directions for pediatric dosages of medications and whose health professionals did not take the time to ensure they did.

    **Read:** [**Dose of Confusion**](https://www.propublica.org/article/tylenol-mcneil-fda-kids-dose-of-confusion)

    "When you pick out colors, it's supposed to be for prom dresses or Christmas pictures, not colors for the lining of her casket." – Christine Hutto, Brianna's mother

    Report on medication errors due to medical terminology miscommunication.

    Include the following aspects in the discussion:

    · Share a personal experience or near miss that medical term miscommunication caused or locate an article to use

    · Summarize the situation including the specific medical term error

    · What could have been done to prevent the miscommunication

    · Discuss the actions you will take during this course so you can provide safe patient care

    · Cite any references. At all times proper grammar, sentence structure, and spelling. Copy and pasting are not allowed. Always use your own words.

    **## hWK3DISCUSSION1HP-114.docx**

    **he Secret Language of the Health Professions**

    Right about now you will likely be feeling a bit overwhelmed. If you are completely overwhelmed, you need to be communicating with your instructor so we can give you extra assistance to be certain you do not fall behind. Being a bit overwhelmed is normal. As you read through the text there are terms and content that seem much like a foreign language to you.

    Let’s give it a go – watch this video:
    [Easy German – Basic Conversation Phrases 1 (03:22)](https://www.youtube.com/watch?v=uO0jWxhVW1A%20)

    Clearly, learning German would take some time and practice. So does learning the language used in the health professions. But when you do learn it, this special language of ours can be rather fun. It makes us members of an exclusive club, the general public is not invited.

    It also poses great safety risks. If we do not learn the language properly, the risk of errors increases as we may get something wrong or be misunderstood by another health professional. If we are not careful the patient has no idea what is going on, or what they are supposed to do. Miscommunication has caused innumerable deaths, including that of infants whose parents did not understand the pharmacy directions for pediatric dosages of medications and whose health professionals did not take the time to ensure they did.

    **Read:** [**Dose of Confusion**](https://www.propublica.org/article/tylenol-mcneil-fda-kids-dose-of-confusion)

    "When you pick out colors, it's supposed to be for prom dresses or Christmas pictures, not colors for the lining of her casket." – Christine Hutto, Brianna's mother

    Report on medication errors due to medical terminology miscommunication.

    Include the following aspects in the discussion:

    · Share a personal experience or near miss that medical term miscommunication caused or locate an article to use

    · Summarize the situation including the specific medical term error

    · What could have been done to prevent the miscommunication

    · Discuss the actions you will take during this course so you can provide safe patient care

    · Cite any references. At all times proper grammar, sentence structure, and spelling. Copy and pasting are not allowed. Always use your own words.