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

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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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