MDC Patient with Generalized Anxiety Disorder SOAP Note Nursing Assignment Help

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week.

Demographic Data 

  • Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant. 

Subjective 

  • Chief Complaint (CC) 
  • History of Present Illness (HPI)?(symptoms) in paragraph format 
  • Past Medical History (PMH):?Current problem-focused and document pertinent information only. 
  • Current Medications:  
  • Medication Allergies: 
  • Social History:?For current problem-focused and document only pertinent information only.  
  • Family History: For current problem-focused and document only pertinent information only.  
  • Review of Systems (ROS) as appropriate:  

Objective 

  • Vital signs 
  • Mental Status Exam 
  • Physical findings listed by body systems, not paragraph form. 
  • Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal) 

Assessment (Diagnosis/ICD10 Code) 

  • Include all diagnoses that apply to this visit. 
  • Include one differential diagnosis. 

Plan 

  • Dx?Plan (lab, x-ray) 
  • Tx?Plan: (meds) 
  • Pt. Education, including specific medication teaching points.? ?  
  • Safety Plan? ? ? ? 
  • Referral/Follow-up 

*Based on population focus, some additional details may be required by faculty Top of Form 

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