The writer is very fast, professional and responded to the review request fast also. Thank you.
Follow these guidelines for APA. This is maternity note ,please adapt to advance primary care
References in APA have to be within a 5-year range.
Make sure you include Psych History as well and also Genitourinary system.
Semester:
SpringCourse:MSN5700C Advanced Practice in Primary Care IPreceptor:ARENCIBIA, ALEXEISClinical Site:AMERICAN CARE (SOUTH TAMPA)Setting Type:
Patient Demographics
Age:
74 years
Race:
Black or African American
Gender:
Male
Insurance:
Medicare
Referral:
Nutritionist
Clinical Information
Time with Patient:
40 minutes
Consult with Preceptor:
15 minutesType of Decision-Making:Moderate complexityReason for Visit:Follow-up (Routine)Chief Complaint:HTN follow upType of HP:ComprehensiveSocial Problems Addressed:Emotional
Prevention
Nutrition/Exercise
Substance Abuse
Procedures/Skills (Observed/Assisted/Performed)
Physical Assessment – Physical Assessment (Perf)
General Skills – EKG (Perf)
General Skills – Vital Signs (Perf)
ICD-10 Diagnosis Codes#1 – I10 – ESSENTIAL (PRIMARY) HYPERTENSION#2 – E66.9 – OBESITY, UNSPECIF
Medications
# OTC Drugs taken regularly:
1# Prescriptions currently prescribed:2# New/Refilled Prescriptions This Visit:1Types of New/Refilled Prescriptions This Visit:
Cardiology – Antilipids
Cardiology – Calcium channel blockers
Adherence Issues with Medications:
Caretaker failure
Financial concerns
Forgetfulness
Other Questions About This Case
Patient’s Primary Language:EnglishSmoking Assessment:HistoryAdvanced Directive:Yes, on file
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