nursing competencies
April 19, 2023
Medical terminology
April 19, 2023

Soap Note: Hypertension

Follow these guidelines for APA. This is maternity note ,please adapt to advance primary careReferences 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 DemographicsAge:74 yearsRace:Black or African AmericanGender:MaleInsurance:MedicareReferral:NutritionistClinical InformationTime with Patient:40 minutesConsult with Preceptor:15 minutesType of Decision-Making:Moderate complexityReason for Visit:Follow-up (Routine)Chief Complaint:HTN follow upType of HP:ComprehensiveSocial Problems Addressed:EmotionalPreventionNutrition/ExerciseSubstance AbuseProcedures/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, UNSPECIFMedications# OTC Drugs taken regularly:1# Prescriptions currently prescribed:2# New/Refilled Prescriptions This Visit:1Types of New/Refilled Prescriptions This Visit:Cardiology – AntilipidsCardiology – Calcium channel blockersAdherence Issues with Medications:Caretaker failureFinancial concernsForgetfulnessOther Questions About This CasePatient’s Primary Language:EnglishSmoking Assessment:HistoryAdvanced Directive:Yes, on filePacks per day:

 
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