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  • [Solved] soap note follow template attached

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    Executive Solution Overview

    this soap note will be on a patient you made up who has schizophernia – 2 years ago **files (2)** – ## soapnotemodule3instructuons.docx – ## psychsoapnote.template.docx **## soapnotemodule3instructuons.docx** **Step 1:** You will use the [Graduate Comprehensive Psychiatric Evaluation Template](https…

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    Assignment Prompt & Instructions

    this soap note will be on a patient you made up who has schizophernia

    – 2 years ago

    **files (2)**

    – ## soapnotemodule3instructuons.docx

    – ## psychsoapnote.template.docx

    **## soapnotemodule3instructuons.docx**

    **Step 1:** You will use the
    [Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724?wrap=1) [Download Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724/download?download_frd=1) to:

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

    2. 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 |

    **## psychsoapnote.template.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****

    **## psychsoapnote.template.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****

    **## soapnotemodule3instructuons.docx**

    **Step 1:** You will use the
    [Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724?wrap=1) [Download Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724/download?download_frd=1) to:

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

    2. 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 |

    **## psychsoapnote.template.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****

    **## soapnotemodule3instructuons.docx**

    **Step 1:** You will use the
    [Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724?wrap=1) [Download Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724/download?download_frd=1) to:

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

    2. 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 |

    **## psychsoapnote.template.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] SOAP note about Premature Adrenarche

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    Discuss a pediatric patient, black female, 5 years old that comes to the office with her mom who is concerning about her daughter having pubic hair and body odor. – [\ \ SOAPNoteTemplate2121.docx](https://www.sweetstudy.com/files/soapnotetemplate2121-docx "SOAPNoteTemplate2121.docx") – 2 years ago

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    Discuss a pediatric patient, black female, 5 years old that comes to the office with her mom who is concerning about her daughter having pubic hair and body odor.

    – [\
    \
    SOAPNoteTemplate2121.docx](https://www.sweetstudy.com/files/soapnotetemplate2121-docx "SOAPNoteTemplate2121.docx")

    – 2 years ago

  • [Solved] Nursing The purpose of this assignment is to evaluate the value of health information technology in the prevention and detection of errors, as well as analysis of unintended consequences and human factors through quality improvement strategies.

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    In-depth study guidance and analytical solution covering Nursing The purpose of this assignment is to evaluate the value of health information technology in the prevention and detection of errors, as well as analysis of unintended consequences and human factors through quality improvement strategies..

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    Assignment Prompt & Instructions

    Full assignment prompt and step-by-step guidance are included in the downloadable solution file.

  • [Solved] Nursing Health Asssessment Assignment

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    – 2 years ago **files (1)** – ## HApowerpoint.docx **## HApowerpoint.docx** **Content Requirements** You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following: 1. **Subjective data:** Chief Co…

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    Assignment Prompt & Instructions

    – 2 years ago

    **files (1)**

    – ## HApowerpoint.docx

    **## HApowerpoint.docx**

    **Content Requirements** You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following:

    1.
    **Subjective data:** Chief Complaint; 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; Review of Systems (ROS)

    2.
    **Objective data:** Medications; Allergies; Past medical history; Family history; Past surgical history; Social history; Labs; Vital signs; Physical exam.

    3.
    **Assessment:** Primary Diagnosis; Differential diagnosis

    4.
    **Plan:** Diagnostic testing; Pharmacologic treatment plan; Non-pharmacologic treatment plan; Anticipatory guidance (primary prevention strategies); Follow up plan.

    5.
    **Other:** Incorporation of current clinical guidelines; Integration of research articles; Role of the Nurse practitioner

    **Submission Instructions:**

    · APA style, including citation of references.

    · The presentation should consist of 10-15 slides and less than 5 minutes in length.

    · Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work

    **## HApowerpoint.docx**

    **Content Requirements** You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following:

    1.
    **Subjective data:** Chief Complaint; 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; Review of Systems (ROS)

    2.
    **Objective data:** Medications; Allergies; Past medical history; Family history; Past surgical history; Social history; Labs; Vital signs; Physical exam.

    3.
    **Assessment:** Primary Diagnosis; Differential diagnosis

    4.
    **Plan:** Diagnostic testing; Pharmacologic treatment plan; Non-pharmacologic treatment plan; Anticipatory guidance (primary prevention strategies); Follow up plan.

    5.
    **Other:** Incorporation of current clinical guidelines; Integration of research articles; Role of the Nurse practitioner

    **Submission Instructions:**

    · APA style, including citation of references.

    · The presentation should consist of 10-15 slides and less than 5 minutes in length.

    · Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work

  • [Solved] Nursing Forensics Assignment –

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    **Purpose:** Review the Forensics PowerPoint, select a relevant article, write a summary, – 2 years ago **files (2)** – ## ForensicsAssignment-PADLET.docx – ForensicsforMedicalProviders_Review.pptx **## ForensicsAssignment-PADLET.docx** **Directions:** **Purpose:** Review the Forensics PowerPoint, …

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    Assignment Prompt & Instructions

    **Purpose:** Review the Forensics PowerPoint, select a relevant article, write a summary,

    – 2 years ago

    **files (2)**

    – ## ForensicsAssignment-PADLET.docx

    – ForensicsforMedicalProviders_Review.pptx

    **## ForensicsAssignment-PADLET.docx**

    **Directions:**

    **Purpose:** Review the Forensics PowerPoint, select a relevant article, write a summary,

    **Your Mission**

    Review the Forensics PowerPoint and select an article relevant to the topic.

    Write a summary of the article and post on Padlet

    | | | |
    | — | — | — |
    | **Forensics Assignment – – Padlet Rubric** |
    | **Criteria** | **Ratings** | **Pts** |
    | Article Selection | | | | |
    | — | — | — |
    | **2 pts**<br>**Excellent**<br>Article is highly relevant and directly connected to the PowerPoint topic. | **1.2 pts**<br>**Good**<br>Article is relevant but may lack strong connection to the topic. | **0 pts**<br>**Needs Improvement**<br>Article is not relevant or unrelated to the topic. | | 2 pts |
    | A Article Summary | | | | |
    | — | — | — |
    | **1 pts**<br>**Excellent**<br>Article is highly relevant and directly connected to the PowerPoint topic. | **0.6 pts**<br>**Good**<br>Article is relevant but may lack strong connection to the topic. | **0 pts**<br>**Needs Improvement**<br>Article is not relevant or unrelated to the topic. | | 1 pts |
    | Use of <br>R references | | | | |
    | — | — | — |
    | **1 pts**<br>**Excellent**<br>Article is properly cited, and references are credible and correctly formatted (APA or other required format). | **0.6 pts**<br>**Good**<br>Citations are present with minor formatting issues. | **0 pts**<br>**Needs Improvement**<br>Little to no citations, or references are missing or incorrect. | | 1 pts |
    | T Response to <br>classmates | | | | |
    | — | — | — |
    | **1 pts**<br>**Excellent**<br>Responds thoughtfully and meaningfully to at least one classmate’s post, adding to the discussion. | **0.6 pts**<br>**Good**<br>Responds to one classmate’s post with relevant comments. | **0 pts**<br>**Needs Improvement**<br>No response to classmates, or the response is irrelevant. | | 1 pts |
    | Total Points: 5 |

    **APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2020-2025 only. (Within the last five years)**

    **Please do not solely use a website as your scholarly reference. It is fine to use it as a supplement, but a journal article or text should be referenced.**

    **Please use North American peer-reviewed journals ONLY.**

    **DO NOT use any European Journal**

    Please use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.

    APA format (if using outside sources).

    **ForensicsforMedicalProviders_Review.pptx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/forensicsformedicalproviders-review-pptx)

    **ForensicsforMedicalProviders_Review.pptx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/forensicsformedicalproviders-review-pptx)

    **## ForensicsAssignment-PADLET.docx**

    **Directions:**

    **Purpose:** Review the Forensics PowerPoint, select a relevant article, write a summary,

    **Your Mission**

    Review the Forensics PowerPoint and select an article relevant to the topic.

    Write a summary of the article and post on Padlet

    | | | |
    | — | — | — |
    | **Forensics Assignment – – Padlet Rubric** |
    | **Criteria** | **Ratings** | **Pts** |
    | Article Selection | | | | |
    | — | — | — |
    | **2 pts**<br>**Excellent**<br>Article is highly relevant and directly connected to the PowerPoint topic. | **1.2 pts**<br>**Good**<br>Article is relevant but may lack strong connection to the topic. | **0 pts**<br>**Needs Improvement**<br>Article is not relevant or unrelated to the topic. | | 2 pts |
    | A Article Summary | | | | |
    | — | — | — |
    | **1 pts**<br>**Excellent**<br>Article is highly relevant and directly connected to the PowerPoint topic. | **0.6 pts**<br>**Good**<br>Article is relevant but may lack strong connection to the topic. | **0 pts**<br>**Needs Improvement**<br>Article is not relevant or unrelated to the topic. | | 1 pts |
    | Use of <br>R references | | | | |
    | — | — | — |
    | **1 pts**<br>**Excellent**<br>Article is properly cited, and references are credible and correctly formatted (APA or other required format). | **0.6 pts**<br>**Good**<br>Citations are present with minor formatting issues. | **0 pts**<br>**Needs Improvement**<br>Little to no citations, or references are missing or incorrect. | | 1 pts |
    | T Response to <br>classmates | | | | |
    | — | — | — |
    | **1 pts**<br>**Excellent**<br>Responds thoughtfully and meaningfully to at least one classmate’s post, adding to the discussion. | **0.6 pts**<br>**Good**<br>Responds to one classmate’s post with relevant comments. | **0 pts**<br>**Needs Improvement**<br>No response to classmates, or the response is irrelevant. | | 1 pts |
    | Total Points: 5 |

    **APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2020-2025 only. (Within the last five years)**

    **Please do not solely use a website as your scholarly reference. It is fine to use it as a supplement, but a journal article or text should be referenced.**

    **Please use North American peer-reviewed journals ONLY.**

    **DO NOT use any European Journal**

    Please use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.

    APA format (if using outside sources).

    **ForensicsforMedicalProviders_Review.pptx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/forensicsformedicalproviders-review-pptx)

    **## ForensicsAssignment-PADLET.docx**

    **Directions:**

    **Purpose:** Review the Forensics PowerPoint, select a relevant article, write a summary,

    **Your Mission**

    Review the Forensics PowerPoint and select an article relevant to the topic.

    Write a summary of the article and post on Padlet

    | | | |
    | — | — | — |
    | **Forensics Assignment – – Padlet Rubric** |
    | **Criteria** | **Ratings** | **Pts** |
    | Article Selection | | | | |
    | — | — | — |
    | **2 pts**<br>**Excellent**<br>Article is highly relevant and directly connected to the PowerPoint topic. | **1.2 pts**<br>**Good**<br>Article is relevant but may lack strong connection to the topic. | **0 pts**<br>**Needs Improvement**<br>Article is not relevant or unrelated to the topic. | | 2 pts |
    | A Article Summary | | | | |
    | — | — | — |
    | **1 pts**<br>**Excellent**<br>Article is highly relevant and directly connected to the PowerPoint topic. | **0.6 pts**<br>**Good**<br>Article is relevant but may lack strong connection to the topic. | **0 pts**<br>**Needs Improvement**<br>Article is not relevant or unrelated to the topic. | | 1 pts |
    | Use of <br>R references | | | | |
    | — | — | — |
    | **1 pts**<br>**Excellent**<br>Article is properly cited, and references are credible and correctly formatted (APA or other required format). | **0.6 pts**<br>**Good**<br>Citations are present with minor formatting issues. | **0 pts**<br>**Needs Improvement**<br>Little to no citations, or references are missing or incorrect. | | 1 pts |
    | T Response to <br>classmates | | | | |
    | — | — | — |
    | **1 pts**<br>**Excellent**<br>Responds thoughtfully and meaningfully to at least one classmate’s post, adding to the discussion. | **0.6 pts**<br>**Good**<br>Responds to one classmate’s post with relevant comments. | **0 pts**<br>**Needs Improvement**<br>No response to classmates, or the response is irrelevant. | | 1 pts |
    | Total Points: 5 |

    **APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2020-2025 only. (Within the last five years)**

    **Please do not solely use a website as your scholarly reference. It is fine to use it as a supplement, but a journal article or text should be referenced.**

    **Please use North American peer-reviewed journals ONLY.**

    **DO NOT use any European Journal**

    Please use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.

    APA format (if using outside sources).

    **ForensicsforMedicalProviders_Review.pptx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/forensicsformedicalproviders-review-pptx)

  • [Solved] NUR 691 B – Change Project Final

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    – 2 years ago **files (1)** – ## finalpaper.docx **## finalpaper.docx** Your final paper will encompass all assignments you have completed thus far. At this point, you will have submitted each section individually and a comprehensive rough draft. You have received extensive feedback. An attempt to i…

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    – 2 years ago

    **files (1)**

    – ## finalpaper.docx

    **## finalpaper.docx**

    Your final paper will encompass all assignments you have completed thus far. At this point, you will have submitted each section individually and a comprehensive rough draft. You have received extensive feedback. An attempt to incorporate all previous assignment feedback should be evident.

    The paper should be between 20 and 30 pages in length, not including the cover page, references, and any appendices. It must follow current APA manual style and format. Each section of the paper should be clearly identified using proper headings. The final paper should be professionally written in a manner suitable for publication.

    **## finalpaper.docx**

    Your final paper will encompass all assignments you have completed thus far. At this point, you will have submitted each section individually and a comprehensive rough draft. You have received extensive feedback. An attempt to incorporate all previous assignment feedback should be evident.

    The paper should be between 20 and 30 pages in length, not including the cover page, references, and any appendices. It must follow current APA manual style and format. Each section of the paper should be clearly identified using proper headings. The final paper should be professionally written in a manner suitable for publication.

  • [Solved] NUR 600 4

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    – 2 years ago **files (1)** – ## NUR600wk4.docx **## NUR600wk4.docx** Please answer the following questions. 1. Describe causes of Upper respiratory infections and drug therapy 2. Discuss triggers of asthma and treatment options 3. Discuss corticosteroids 4. Describe chronic bronchitis and treat…

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    Assignment Prompt & Instructions

    – 2 years ago

    **files (1)**

    – ## NUR600wk4.docx

    **## NUR600wk4.docx**

    Please answer the following questions.

    1. Describe causes of Upper respiratory infections and drug therapy

    2. Discuss triggers of asthma and treatment options

    3. Discuss corticosteroids

    4. Describe chronic bronchitis and treatment options

    **INSTRUCTIONS:**

    · Your initial post should be at least
    **500 words**, formatted and cited in the current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

    · Each question
    **must be answered individually** as in bullet points.
    **Not** in an essay format.

    · Example: Question 1, followed by the answer to question 1; Question 2, followed by the answer to question 2; and so forth.

    · Please do not use textbooks as reference only peer-reviewed scholarly articles from within 4 years’ time.

    · Please ensure APA formatting is correct

    ![A screenshot of a computer AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/nur-600-4)

    ## image1.png

    **## NUR600wk4.docx**

    Please answer the following questions.

    1. Describe causes of Upper respiratory infections and drug therapy

    2. Discuss triggers of asthma and treatment options

    3. Discuss corticosteroids

    4. Describe chronic bronchitis and treatment options

    **INSTRUCTIONS:**

    · Your initial post should be at least
    **500 words**, formatted and cited in the current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

    · Each question
    **must be answered individually** as in bullet points.
    **Not** in an essay format.

    · Example: Question 1, followed by the answer to question 1; Question 2, followed by the answer to question 2; and so forth.

    · Please do not use textbooks as reference only peer-reviewed scholarly articles from within 4 years’ time.

    · Please ensure APA formatting is correct

    ![A screenshot of a computer AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/nur-600-4)

    ## image1.png

  • [Solved] What methods can nurses use to actively influence health policies and legislation?

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    In-depth study guidance and analytical solution covering What methods can nurses use to actively influence health policies and legislation?.

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    Assignment Prompt & Instructions

    Full assignment prompt and step-by-step guidance are included in the downloadable solution file.

  • [Solved] Weekly clinical week 4

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    **Describe your clinical experience for this week. 4 year old male abdominal pain** – **Did you face any challenges, any success? If so, what were they?** – **Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential …

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    Assignment Prompt & Instructions

    **Describe your clinical experience for this week. 4 year old male abdominal pain**

    – **Did you face any challenges, any success? If so, what were they?**
    – **Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.**
    – **Mention the health promotion intervention for this patient.**
    – **What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?**
    – **Support your plan of care with the current peer-reviewed research guideline.**

    **Submission Instructions:**

    – **Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources Within 5 years 2020-2025**

    – 2 years ago

  • [Solved] W4 CL-D

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    500 WORDS, 2 CITATIONS APA – 2 years ago

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    Assignment Prompt & Instructions

    500 WORDS, 2 CITATIONS APA

    – 2 years ago