Assignment Prompt & Instructions
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****