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    pls see intructions attached for further instructions – ## 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 psychiatr…

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    Assignment Prompt & Instructions

    pls see intructions attached for further instructions

    – ## 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****

    – 1
    – 2

  • [Solved] DLRL Week 9 Discussion

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    **To prepare:** – Review the readings and media in the Learning Resources about analyzing literature and outlining for topic themes. **Post** your response to the following: – Create a list of themes you have identified from your annotated bibliography and describe what they related to in terms of t…

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    Assignment Prompt & Instructions

    **To prepare:**
    – Review the readings and media in the Learning Resources about analyzing literature and outlining for topic themes.
    **Post** your response to the following:
    – Create a list of themes you have identified from your annotated bibliography and describe what they related to in terms of the social problem and/or the research problem (the gap).
    **Note:** Your posts should be substantial (500 words minimum), supported with scholarly evidence from your research and/or the Learning Resources, and properly cited using APA style.

  • [Solved] week 3

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    **Week 3** **Discussion: Nursing Leadership and Change Management** Being cost conscious as a nurse and a nurse leader can be challenging. There are multiple considerations that contribute to cost-consciousness that should be kept in mind. As direct caregivers, nurses are often involved in determini…

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    **Week 3** **Discussion: Nursing Leadership and Change Management**
    Being cost conscious as a nurse and a nurse leader can be challenging. There are multiple considerations that contribute to cost-consciousness that should be kept in mind. As direct caregivers, nurses are often involved in determining the type and quantity of resources used for patients. This includes supplies, personnel, and time. Decisions made by nurse leaders will directly impact the cost of care for patients cared for within their organization.
    In this week’s discussion, reflect on the role of the nurse leader in fiscal management decision making. Address the following:
    – Provide two different examples that demonstrate how nurse leaders can impact cost of care through cost-containment efforts surrounding budgeting, expense reporting, personnel/staffing decisions, or reimbursement.
    – Discuss how implementing evidence-based practice can contribute to cost-containment efforts within healthcare organizations.
    – Provide one example of an evidence-based change that can impact healthcare costs.
    – Reflect on your work as a nurse. After reviewing the content in this module, how will your practice change in the future concerning fiscal and resource management? What specific changes will you make in your practice?

  • [Solved] Two Students Responses (300-400 Words)

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    **Respond to** at least **two** of your colleagues’ posts (on different days). In each case, expand on your colleague’s posting by offering a new perspective or insight or offering additional (new) supporting information for consideration. **Note:** Your responses to colleagues should be substantial…

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    **Respond to** at least **two** of your colleagues’ posts (on different days). In each case, expand on your colleague’s posting by offering a new perspective or insight or offering additional (new) supporting information for consideration.
    **Note:** Your responses to colleagues should be substantial (250 words minimum), supported with scholarly evidence from your research and/or the Learning Resources, and properly cited using APA style. Your responses should enrich the initial post by supporting and/or adding a fresh viewpoint and be constructive, enhancing the learning experience for all students

  • [Solved] Reflections on Evidence-Based Practice, Clinical Practice Guidelines, and Standards of Care

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    ## **Reflections on Evidence-Based Practice, Clinical Practice Guidelines, and Standards of Care**

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    Assignment Prompt & Instructions

    ## **Reflections on Evidence-Based Practice, Clinical Practice Guidelines, and Standards of Care**

  • [Solved] DLRL Week 9 Assignment

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    **To prepare:** – Review the resources about analyzing literature and outlining for topic themes. – Using your annotated bibliography, analyze the literature to find themes under which you can place each article. The themes should demonstrate that your argument is worthwhile and justified, leading t…

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    Assignment Prompt & Instructions

    **To prepare:**
    – Review the resources about analyzing literature and outlining for topic themes.
    – Using your annotated bibliography, analyze the literature to find themes under which you can place each article. The themes should demonstrate that your argument is worthwhile and justified, leading to the gap in the literature.
    – Review the web resource _Evidence-Based Arguments_ in the Learning Resources. Focus on the section titled “Using Evidence.”
    **Assignment:** 3- or 4-page paper, not including title page or references page(s)
    – Using your annotated bibliography, create a literature review outline in which you:
    – Identify the themes that are represented.
    – Then, group your annotated bibliography entries under each theme. **Note:** This represents the start of the subject headings for the Literature Review chapter of your dissertation.

  • [Solved] S4

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    In-depth study guidance and analytical solution covering S4.

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    Assignment Prompt & Instructions

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

  • [Solved] WH D4

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    In-depth study guidance and analytical solution covering WH D4.

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

  • [Solved] FNP CL2 D4

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    In-depth study guidance and analytical solution covering FNP CL2 D4.

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

  • [Solved] rrr…

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    \ good.pdf](https://www.sweetstudy.com/files/good-pdf-10355631 "good.pdf")

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