23 Feb Follow these guidelines for APA. This is
Follow these guidelines for APA. This is maternity note ,please adapt to advance primary care
References in APA have to be within a 5-year range.
Make sure you include Psych History as well and also Genitourinary system.
SpringCourse:MSN5700C Advanced Practice in Primary Care IPreceptor:ARENCIBIA, ALEXEISClinical Site:AMERICAN CARE (SOUTH TAMPA)Setting Type:
Black or African American
Time with Patient:
Consult with Preceptor:
15 minutesType of Decision-Making:Moderate complexityReason for Visit:Follow-up (Routine)Chief Complaint:HTN follow upType of HP:ComprehensiveSocial Problems Addressed:Emotional
Physical Assessment – Physical Assessment (Perf)
General Skills – EKG (Perf)
General Skills – Vital Signs (Perf)
ICD-10 Diagnosis Codes#1 – I10 - ESSENTIAL (PRIMARY) HYPERTENSION#2 – E66.9 - OBESITY, UNSPECIF
# OTC Drugs taken regularly:
1# Prescriptions currently prescribed:2# New/Refilled Prescriptions This Visit:1Types of New/Refilled Prescriptions This Visit:
Cardiology – Antilipids
Cardiology – Calcium channel blockers
Adherence Issues with Medications:
Other Questions About This Case
Patient's Primary Language:EnglishSmoking Assessment:HistoryAdvanced Directive:Yes, on file
Packs per day:
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