Our Services

Get 15% Discount on your First Order

Demographic Data · Patient’s age and patient’s gender identity · IT MUST BE HIPAA compliant. Subjective

July 12, 2024

Demographic Data

· Patient’s age and patient’s gender identity

· IT MUST BE HIPAA compliant.

Subjective

·
Chief Complaint (CC):

· Place the patient’s CC complaint in Quotes

·
History of Present Illness (HPI):

· Reason for an appointment today.

· The events that led to hospitalization or clinic visits today.

· Include symptoms, relieving factors, and past compliance or non-compliance with medications

· Any adverse effects from past medication use

· Sleep patterns – number of hours of sleep per day, early wakefulness, inability to initiate sleep, inability to stay asleep, etc.

· Suicide or homicide thoughts present

· Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits, or issues noted?

· Presence/description of psychosis (if psychosis, command or non-command)

·
Past Psychiatric History (PSH):

· Past psychiatric diagnoses

· Past hospitalizations

· Past psychiatric medications use

· Any non-compliance issues in the past?

· Any meds that didn’t work for this patient?

·
Family History of Psychiatric Conditions or Diagnoses:

· Mother/father, siblings, grandparents, or direct relatives

·
Social History: 

· Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, and history of personal abuse (including sexual, emotional, or physical).

·
Allergies:

· To medications, foods, chemicals, and others.

·
Review of Systems (ROS) (Physical Complaints):

· Any physical complaints by the body system? (Respiratory, Cardiac, Renal, etc.)

Objective

·
Mental Status Exam:

· This is not a physical exam.

· Mental Status Exam (MSE)

Assessment (Diagnosis)

·
Differentials

· Two (2) differential diagnoses with ICD-10 codes.

· Must include rationale using DSM-5 Criteria (Required)

· Why didn’t you pick these as a major diagnosis?

·
Working Diagnosis

· Final or working diagnosis (1), with ICD-10 code.

· Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly)

Plan

·
Treatment Plan (Tx Plan):

· Pharmacologic: Include complete information for each medication(s) prescribed

· Refill Provided: Include complete information for each medication(s) refilled

·
Patient Education:

· Including specific medication teaching points

· Was the risk versus benefit of the current treatment plan addressed for meds or treatment

· Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed?

·
Prognosis:

· Make Decision for prognosis: Good, Fair, Poor

· Provide brief statement lending support for or against the decided prognosis.

·
Therapy Recommendations:

· Type(s) of therapy recommended.

·
Referral/Follow-up:

· Did you recommend follow-up with a Psychiatrist, PCP, or other specialist or healthcare professionals?

· When is the subsequent follow-up?

· Include the rationale for the F/U recommendation or referral.

Reference(s):

· Include American Psychological Association (APA) formatted references.

· Include a reference from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5.

>Nursing homework help

Share This Post

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

NURS-6051C-47 (05/26/2025-08/10/2025)-PT27 please respond to the posts attached. Rebecca Brown Jun 10 7:09pm Manage

NURS-6051C-47 (05/26/2025-08/10/2025)-PT27 please respond to the posts attached. Rebecca Brown Jun 10 7:09pm Manage Discussion by Rebecca Brown Reply from Rebecca Brown Implementation Healthcare electronic documentation technology has been recently introduced for my current employer in the maximum-security prison for the Department of Corrections. The newly designed electronic record platform

For this PPT you are an advocate for full practice authority for your APRN specialty. You are addressing a group of legislators.

Template and rubric are included. SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics

Template and rubric are included. SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics Chief Complaint (Reason for seeking health care) History of Present Illness (HPI) Allergies Review of Systems (ROS) General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP:

Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!

Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you! Case Study Discussion 2 Study Discussion Instructions Scenario: A 32 year old female reports a history of depression, crying spells, substance abuse, and behaviors that include eating and sleeping very little, talking

SOAP Note 2 Patient is a 77 year male coming in because he keeps on wetting the

SOAP Note 2 Patient is a 77 year male coming in because he keeps on wetting the bed. Has no history of surgeries. Has a wife and 2 kids. No family histories. Wife does have type 2 diabetes. And he has mild hypertension but that started in his early

Blog: How Has Nursing Informatics and Technology Impacted Your Practice? For this Discussion, you will explore the impact of digital technology on

Blog: How Has Nursing Informatics and Technology Impacted Your Practice? For this Discussion, you will explore the impact of digital technology on nursing practice. Consider the influence these technologies may have on nursing practice, and what skills you might need to hone in on in order to address these needs.

Weekly Clinical Experience 4 Patient came in because she is having trouble

Weekly Clinical Experience 4 Patient came in because she is having trouble sleeping. She is 77 years old Describe your clinical experience for this week. · Did you face any challenges, any success? If so, what were they? · Describe the assessment of a patient, detailing the signs and

Case 4 An 82-year-old man recently returned to the long-term care facility after

Case 4 An 82-year-old man recently returned to the long-term care facility after hospitalization for open reduction internal fixation of the right hip. He has been divorced for over 50 years and has two adult children who visit him frequently in the nursing home. He has a 5-year history

see attachments. The paper should only be 2-3 pages long and should be written as a formal paper. Information must be in complete sentences (not

see attachments. The paper should only be 2-3 pages long and should be written as a formal paper. Information must be in complete sentences (not phrases). Include all aspects of the bullet points in your paper. The paper is about how you can compile information into a complete but concise

create a concept map using the case study in the power point and the concept map outline NUR 357 Concept Map Guidelines

create a concept map using the case study in the power point and the concept map outline NUR 357 Concept Map Guidelines Concept Map Description: A concept map is a picture or chart that illustrates the relationships between the patient’s medical diagnosis(es), the symptoms he/she is demonstrating, the patient lab

Well-child SOAP Note Format Demographic Data · Age, and gender (must be HIPAA compliant)

Well-child SOAP Note Format Demographic Data · Age, and gender (must be HIPAA compliant) Subjective · ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today? · Interval Events/History: · Nutrition: · Elimination: · Sleep: · Medications: · Allergies: ·

see attachment Case Scenario 1- Complete the chart and answer the case scenario Kelly is a 19-year-old female who comes to your clinic

see attachment Case Scenario 1- Complete the chart and answer the case scenario Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is usually worse just prior to and during the first two days of her menses. The pain is sometimes so severe

Week 6 Discussion Part I Table 1 Differential Diagnosis Pediatric Limp

Week 6 Discussion Part I Table 1 Differential Diagnosis Pediatric Limp Complete the table. CC limp Condition Age Pain (+ or -) Historical Findings Clinical Findings Causative Factors Management Developmental Dysplasia of Hip Leg-length Inequality Juvenile Arthritis Slipped capital femoral epiphysis (SCFE) Legg-Calve-Perthes disease Transient synovitis Trauma Neoplasm Septic arthritis

MENTAL STATUS EXAM GUIDE Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational

MENTAL STATUS EXAM GUIDE Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social services): What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social worker note: Compare your impression of the

Comprehensive Psychiatric Evaluation Template With Psychotherapy Note Encounter date:

Comprehensive Psychiatric Evaluation Template With Psychotherapy Note 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

1

1 3 Awakening the DNP Spirit of the Scientific Underpinnings Your Name (without credentials) Miami Regional University DNP7100: Evaluation of Evidence for Practice Professor Name Month, Year Title (Introduction – not labeled ‘Introduction’) Introduce your topic of interest for practice change and its general area of either (a) clinical outcomes,

The purpose of this assignment is to explore and analyze regulatory agencies that play a critical role in governing health and the healthcare system

The purpose of this assignment is to explore and analyze regulatory agencies that play a critical role in governing health and the healthcare system within the United States. This will help you understand the frameworks that guide healthcare practice, especially as it relates to your role as a Family Nurse

Describe causes of Upper respiratory infections and drug therapy Discuss triggers of asthma and treatment options Discuss corticosteroids Describe

Describe causes of Upper respiratory infections and drug therapy Discuss triggers of asthma and treatment options Discuss corticosteroids Describe chronic bronchitis and treatment options Describe diagnostic criteria for nausea and vomiting and treatment recommendations Discuss symptoms of GERD, complications, and drug management Compare and contrast Crohn’s disease and Ulcerative colitis