Soap Note: Hypertension

  

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

Packs per day: