Tag: Nursing

  • [Solved] WK6 ASSIGNMENT HP-213

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    COMPLETE WORK BY FILLING IN THE BLANK. DUE ASAP TODAY!!! – ## WK6ASSIGNMENTHP-213.rtf **## WK6ASSIGNMENTHP-213.rtf** WK6 ASSIGNMENT HP-213 Instructions: Complete each statement. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. – Procedu…

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    COMPLETE WORK BY FILLING IN THE BLANK. DUE ASAP TODAY!!!

    – ## WK6ASSIGNMENTHP-213.rtf

    **## WK6ASSIGNMENTHP-213.rtf**

    WK6 ASSIGNMENT HP-213

    Instructions: Complete each statement. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code.

    – Procedure descriptions for codes in the Radiology section include type of FILL IN BLANK, FILL IN BLANK anatomical site, and use of contrast material.
    – Services provided by the radiologic technologist include performing diagnostic imaging examinations and administering radiation therapy treatments; they are considered the FILL IN BLANK component.

    3) Which services, provided by just the physician, include supervising the performance of a diagnostic imaging procedure, interpreting imaging films, and documenting the imaging report? CHOOSE THE CORRECT ANSWER

    Responses

    – professional component

    unlisted service

    technical component

    global service

    4) Combined technical and professional components reported with a CPT radiology code are considered a FILL IN BLANK service.

    5) When a significant, separately identifiable evaluation and management (E/M) service is provided by the radiologist FILL IN BLANK
    _from the radiographic procedure_, an appropriate E/M code is reported.

    6) Bone age study. FILL IN BLANK

    7) Joint survey, single view, left knee and ankle joints. FILL IN BLANK

    8) Limited osseous survey radiological examination to detect osteoporosis. FILL IN BLANK

    9) Vertebral fracture assessment via dual-energy x-ray absorptiometry. FILL IN BLANK

    10) Bone length scanogram study. FILL IN BLANK

    11) The unit of pathology service is a(n) FILL IN BLANK, which is tissue submitted for individual and separate examination and pathological diagnosis.

    12) During the same operative session, the surgeon submitted "incidental appendix" tissue and a section of fallopian tube (as the result of a sterilization procedure) for pathological evaluation. Refer to the notes located below the Surgical Pathology subsection (codes 88300–88399) to determine whether one or two codes are reported. Code 88302 is reported FILL IN BLANK (once/twice).

    13) It is appropriate to code and report multiple pathology and laboratory procedures separately if they are provided on the FILL IN BLANK date of service.

    14) A service or procedure for which there is no CPT code available is reported with an unlisted code, and a(n) FILL IN BLANK report is attached to the submitted claim.

    15) When procedures or services are repeated on the same date of service to obtain multiple results, add modifier -91 to the reported pathology and laboratory code(s). It is not appropriate to add modifier FILL IN BLANK to pathology and laboratory codes.

    **## WK6ASSIGNMENTHP-213.rtf**

    WK6 ASSIGNMENT HP-213

    Instructions: Complete each statement. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code.

    – Procedure descriptions for codes in the Radiology section include type of FILL IN BLANK, FILL IN BLANK anatomical site, and use of contrast material.
    – Services provided by the radiologic technologist include performing diagnostic imaging examinations and administering radiation therapy treatments; they are considered the FILL IN BLANK component.

    3) Which services, provided by just the physician, include supervising the performance of a diagnostic imaging procedure, interpreting imaging films, and documenting the imaging report? CHOOSE THE CORRECT ANSWER

    Responses

    – professional component

    unlisted service

    technical component

    global service

    4) Combined technical and professional components reported with a CPT radiology code are considered a FILL IN BLANK service.

    5) When a significant, separately identifiable evaluation and management (E/M) service is provided by the radiologist FILL IN BLANK
    _from the radiographic procedure_, an appropriate E/M code is reported.

    6) Bone age study. FILL IN BLANK

    7) Joint survey, single view, left knee and ankle joints. FILL IN BLANK

    8) Limited osseous survey radiological examination to detect osteoporosis. FILL IN BLANK

    9) Vertebral fracture assessment via dual-energy x-ray absorptiometry. FILL IN BLANK

    10) Bone length scanogram study. FILL IN BLANK

    11) The unit of pathology service is a(n) FILL IN BLANK, which is tissue submitted for individual and separate examination and pathological diagnosis.

    12) During the same operative session, the surgeon submitted "incidental appendix" tissue and a section of fallopian tube (as the result of a sterilization procedure) for pathological evaluation. Refer to the notes located below the Surgical Pathology subsection (codes 88300–88399) to determine whether one or two codes are reported. Code 88302 is reported FILL IN BLANK (once/twice).

    13) It is appropriate to code and report multiple pathology and laboratory procedures separately if they are provided on the FILL IN BLANK date of service.

    14) A service or procedure for which there is no CPT code available is reported with an unlisted code, and a(n) FILL IN BLANK report is attached to the submitted claim.

    15) When procedures or services are repeated on the same date of service to obtain multiple results, add modifier -91 to the reported pathology and laboratory code(s). It is not appropriate to add modifier FILL IN BLANK to pathology and laboratory codes.

  • [Solved] discussion board 5

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  • [Solved] discussion board 6

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  • [Solved] Genogram

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    – ## Genogram.docx **## Genogram.docx** **Genogram** A genogram is structurally like a family tree but serves a different purpose. Imagine a genogram as a family tree with much more detail about how the family members interact with one another. For example, a family tree might show us that "Emily an…

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    – ## Genogram.docx

    **## Genogram.docx**

    **Genogram**

    A genogram is structurally like a family tree but serves a different purpose. Imagine a genogram as a family tree with much more detail about how the family members interact with one another. For example, a family tree might show us that "Emily and Kevin are married," while a genogram could tell us that "Jon and Jenny are married, but they are emotionally distant from one another.” A genogram becomes most valuable when it includes information about several generations. Patterns that are usually hard to decipher seem to jump out once they've been mapped on paper.

    For this assignment, construct a three-generation genogram of your family to assess your family system and family culture. Your genogram is expected to be correct & professionally completed. Identify the patterns and significant themes in your family of origin using your knowledge of the family models discussed in class. Discuss how these patterns could influence or influence you as an individual, parent, and partner. In what way do you think your cultural background influences your work with families? Examine how your culture and family patterns may be a barrier or strength in working with families. Your genogram and discussion should be 2-3 pages (double-spaced).

    **Directions**

    Develop a genogram illustration that addresses the following criteria:

    1. Choose a family (for this assignment, this can be your own family)

    2. Draw three generations of genealogy, legal family, pets, and others who have played an integral role in the family, if applicable.

    3. Use only standardized genogram symbols.

    4. Show structure of family members: siblings, aunts/uncles, grandparents, remarriages, blended families (step-members and half-siblings), divorces, pets, close family friends, and god families.

    5. List dates of birth/death, dates of marriage, and divorce. Include race, ethnicity, culture, place of birth, residency, cause of death, mental health, and substance abuse issues.

    6. Identify family characteristics, i.e., family structure, type of marriage/parental union, length of the relationship, type of family, and authority pattern (who has the power).

    7. Identify emotional patterns, i.e., close, conflicted, cutoff, distant, unknown, passive-aggressive (or fused & conflicted).

    8. Identify family or generational values and issues and patterns: Occupation, education, hobbies, military duty, work ethic, family business, religion, addiction/recovery, incarceration, homicide, suicide, reunions, parenting style, mental illness, emigration from the country of birth, marriage within or outside the culture, sexuality, cancer, longevity, foster care, adoption, and child abuse. Every generation manifests its values and issues differently.

    9. Identify social patterns, i.e., neighborhoods, communities, places of worship, work and education, and social clubs.

    **## Genogram.docx**

    **Genogram**

    A genogram is structurally like a family tree but serves a different purpose. Imagine a genogram as a family tree with much more detail about how the family members interact with one another. For example, a family tree might show us that "Emily and Kevin are married," while a genogram could tell us that "Jon and Jenny are married, but they are emotionally distant from one another.” A genogram becomes most valuable when it includes information about several generations. Patterns that are usually hard to decipher seem to jump out once they've been mapped on paper.

    For this assignment, construct a three-generation genogram of your family to assess your family system and family culture. Your genogram is expected to be correct & professionally completed. Identify the patterns and significant themes in your family of origin using your knowledge of the family models discussed in class. Discuss how these patterns could influence or influence you as an individual, parent, and partner. In what way do you think your cultural background influences your work with families? Examine how your culture and family patterns may be a barrier or strength in working with families. Your genogram and discussion should be 2-3 pages (double-spaced).

    **Directions**

    Develop a genogram illustration that addresses the following criteria:

    1. Choose a family (for this assignment, this can be your own family)

    2. Draw three generations of genealogy, legal family, pets, and others who have played an integral role in the family, if applicable.

    3. Use only standardized genogram symbols.

    4. Show structure of family members: siblings, aunts/uncles, grandparents, remarriages, blended families (step-members and half-siblings), divorces, pets, close family friends, and god families.

    5. List dates of birth/death, dates of marriage, and divorce. Include race, ethnicity, culture, place of birth, residency, cause of death, mental health, and substance abuse issues.

    6. Identify family characteristics, i.e., family structure, type of marriage/parental union, length of the relationship, type of family, and authority pattern (who has the power).

    7. Identify emotional patterns, i.e., close, conflicted, cutoff, distant, unknown, passive-aggressive (or fused & conflicted).

    8. Identify family or generational values and issues and patterns: Occupation, education, hobbies, military duty, work ethic, family business, religion, addiction/recovery, incarceration, homicide, suicide, reunions, parenting style, mental illness, emigration from the country of birth, marriage within or outside the culture, sexuality, cancer, longevity, foster care, adoption, and child abuse. Every generation manifests its values and issues differently.

    9. Identify social patterns, i.e., neighborhoods, communities, places of worship, work and education, and social clubs.

  • [Solved] mod 4 507

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  • [Solved] 507 CL

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    In-depth study guidance and analytical solution covering 507 CL.

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  • [Solved] WH D4

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

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  • [Solved] FNP CL2 D4

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

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  • [Solved] Wk 9

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    **Part 1: Work Environment Assessment (1-2 pages)** – Review the Work Environment Assessment Template you completed for this Module’s Discussion. – Describe the results of the Work Environment Assessment you completed on your workplace. – Identify two things that surprised you about the results and …

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    **Part 1: Work Environment Assessment (1-2 pages)**
    – Review the Work Environment Assessment Template you completed for this Module’s Discussion.
    – Describe the results of the Work Environment Assessment you completed on your workplace.
    – Identify two things that surprised you about the results and one idea you believed prior to conducting the Assessment that was confirmed.
    – Explain what the results of the Assessment suggest about the health and civility of your workplace.
    **Part 2: Reviewing the Literature (1-2 pages)**
    – Briefly describe the theory or concept presented in the article(s) you selected.
    – Explain how the theory or concept presented in the article(s) relates to the results of your Work Environment Assessment.
    – Explain how your organization could apply the theory highlighted in your selected article(s) to improve organizational health and/or create stronger work teams. Be specific and provide examples.
    **Part 3: Evidence-Based Strategies to Create High-Performance Interprofessional Teams (1–2 pages)**
    – Recommend at least two strategies, supported in the literature, that can be implemented to address any shortcomings revealed in your Work Environment Assessment.
    – Recommend at least two strategies that can be implemented to bolster successful practices revealed in your Work Environment Assessment.

  • [Solved] soap note

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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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    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****

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