(Pupil Title)
Miami Regional College
Date of Encounter:
Preceptor/Clinical Website:
Clinical Teacher: Patricio Bidart MSN, APRN, FNP-C
Cleaning soap Notice # ____ Predominant Prognosis ______________
PATIENT INFORMATION
Title:
Age:
Gender at Start:
Gender Id:
Supply:
Allergy symptoms:
Present Drugs:
•
PMH:
Immunizations:
Preventive Care:
Surgical Historical past:
Household Historical past:
Social Historical past:
Sexual Orientation:
Diet Historical past:
Subjective Information:
Chief Criticism:
Symptom Assessment/HPI:
The affected person is …
Assessment of Programs (ROS) (This part is what the affected person says, due to this fact ought to state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Goal Information:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter along with your affected person and your findings ( together with subjective and goal knowledge)
Instance : “Pt got here in to our clinic c/o of ear ache. Pt states that the ache began three days in the past after swimming. Pt denies discharge and many others… on examination I famous this and that and many others.)
Predominant Prognosis
(Embrace the title of your Predominant Prognosis together with its ICD10 I10. (Take a look at PDF instance offered) Embrace the in-text reference/s as per APA model sixth or seventh Version.
Differential analysis (minimal three)
–
–
–
PLAN:
Labs and Diagnostic Check to be ordered (if relevant)
• –
• –
Pharmacological therapy:
–
Non-Pharmacologic therapy:
Training (present essentially the most related ones tailor-made to your affected person)
Observe-ups/Referrals
References (in APA Fashion)
Examples
Codina Leik, M. T. (2014). Household Nurse Practitioner Certification Intensive Assessment (2nd ed.).
ISBN 978-Zero-8261-3424-Zero
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Seek the advice of 2010
(25th ed.). Print (The 5-Minute Seek the advice of Sequence).
——
Miami Regional College (Pupil Title)
Date of First Encounter:
Clinical Teacher: Patricio Bidart MSN, APRN, FNP-C Preceptor/Clinical Website: Patricio Bidart MSN, APRN, FNP-C Clinical Website: Patricio Bidart MSN, APRN, FNP
Cleaning soap Notice #
INFORMATION ABOUT THE PATIENT
Title: sAge:
Start Gender:
Gender Identification:
Allergy symptoms:
Drugs in Use:
• PMH: Vaccinations:
Preventive Medication:
Surgical Background:
Social Historical past: Household Historical past: Sexual Orientation:
Historical past of Diet:
Subjective Data:
The affected person is…, in accordance with the symptom Assessment/HPI.
System Analysis (ROS) (As a result of this part is what the affected person says, it ought to start with Pt denies or Pt states…..)
CONSTITUTIONAL:
NEUROLOGIC:
HEENT: RESPIRATORY: CARDIOVASCULAR: GASTROINTESTINAL: GENITOURINARY: MUSCULOSKELETAL: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN:
VITAL SIGNS: OBJECTIVE DATA:
OVERALL APPEARANCE:
NEUROLOGIC:
CARDIOVASCULAR: HEENT
RESPIRATORY: GASTROINTESTINAL: MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT: (In a paragraph please state “your encounter along with your affected person and your findings ( together with subjective and goal knowledge) Instance : “Pt got here in to our
