Comprehensive Psychiatric Evaluation 2

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Home>Homework Answsers>Nursing homework helppsychAPRNfocus only on step 1, using the template to complete assignment10 months ago28.10.202430Report issuefiles (3)soapnotetemplate.docxScreenshot2024-10-25at15.40.13.pngsoapnoterubric.docxsoapnotetemplate.docxPsychiatric SOAP Note TemplateEncounter date: ________________________Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____Reason for Seeking Health Care: ______________________________________________HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SI/HI:_______________________________________________________________________________Sleep:_________________________________________Appetite:________________________Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________Current perception of Health: Excellent Good Fair PoorPsychiatric History:Inpatient hospitalizations:DateHospitalDiagnosesLength of StayOutpatient psychiatric treatment:DateHospitalDiagnosesLength of StayDetox/Inpatient substance treatment:DateHospitalDiagnosesLength of StayHistory of suicide attempts and/or self injurious behaviors:____________________________________Past Medical History· Major/Chronic Illnesses____________________________________________________· Trauma/Injury ___________________________________________________________· Hospitalizations __________________________________________________________Past Surgical History___________________________________________________________Current psychotropic medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________Current prescription medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________OTC/Nutritionals/Herbal/Complementary therapy:_________________________________________ _________________________________________________________________________ ________________________________Substance use:(alcohol, marijuana, cocaine, caffeine, cigarettes)SubstanceAmountFrequencyLength of UseFamily Psychiatric History:_____________________________________________________Social HistoryLives: Single family House/Condo/ with stairs: ___________Marital Status:________Education:____________________________Employment Status: ______Current/Previous occupation type: _________________Exposure to:___Smoke____ ETOH ____Recreational Drug Use: __________________Sexual Orientation:_______ Sexual Activity: ____Contraception Use: ____________Family Composition:Family/Mother/Father/Alone: _____________________________Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________________________________________________________________________________Health MaintenanceScreening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____Exposures:Immunization HX:Review of Systems:General:HEENT:Neck:Lungs:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Activity & Exercise:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Physical ExamBP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____General:HEENT:Neck:Pulmonary:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Derm:Psychosocial:Misc.Mental Status ExamAppearance:Behavior:Speech:Mood:Affect:Thought Content:Thought Process:Cognition/Intelligence:Clinical Insight:Clinical Judgment:Significant Data/Contributing Dx/Labs/Misc.Plan:Differential Diagnoses1.2.Principal Diagnoses1.2.PlanDiagnosis #1Diagnostic Testing/Screening:Pharmacological Treatment:Non-Pharmacological Treatment:Education:Referrals:Follow-up:Anticipatory Guidance:Diagnosis #2Diagnostic Testingg/Screenin:Pharmacological Treatment:Non-Pharmacological Treatment:Education:Referrals:Follow-up:Anticipatory Guidance:Signature (with appropriate credentials): __________________________________________Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________DEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________Refill:_________________No SubstitutionSignature:____________________________________________________________Rev. 10162021 LMimage1.pngScreenshot2024-10-25at15.40.13.pngThis file is too large to display.View in new windowsoapnoterubric.docxThis file is too large to display.View in new windowsoapnoterubric.docxThis file is too large to display.View in new windowsoapnotetemplate.docxPsychiatric SOAP Note TemplateEncounter date: ________________________Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____Reason for Seeking Health Care: ______________________________________________HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SI/HI:_______________________________________________________________________________Sleep:_________________________________________Appetite:________________________Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________Current perception of Health: Excellent Good Fair PoorPsychiatric History:Inpatient hospitalizations:DateHospitalDiagnosesLength of StayOutpatient psychiatric treatment:DateHospitalDiagnosesLength of StayDetox/Inpatient substance treatment:DateHospitalDiagnosesLength of StayHistory of suicide attempts and/or self injurious behaviors:____________________________________Past Medical History· Major/Chronic Illnesses____________________________________________________· Trauma/Injury ___________________________________________________________· Hospitalizations __________________________________________________________Past Surgical History___________________________________________________________Current psychotropic medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________Current prescription medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________OTC/Nutritionals/Herbal/Complementary therapy:_________________________________________ _________________________________________________________________________ ________________________________Substance use:(alcohol, marijuana, cocaine, caffeine, cigarettes)SubstanceAmountFrequencyLength of UseFamily Psychiatric History:_____________________________________________________Social HistoryLives: Single family House/Condo/ with stairs: ___________Marital Status:________Education:____________________________Employment Status: ______Current/Previous occupation type: _________________Exposure to:___Smoke____ ETOH ____Recreational Drug Use: __________________Sexual Orientation:_______ Sexual Activity: ____Contraception Use: ____________Family Composition:Family/Mother/Father/Alone: _____________________________Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________________________________________________________________________________Health MaintenanceScreening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____Exposures:Immunization HX:Review of Systems:General:HEENT:Neck:Lungs:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Activity & Exercise:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Physical ExamBP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____General:HEENT:Neck:Pulmonary:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Derm:Psychosocial:Misc.Mental Status ExamAppearance:Behavior:Speech:Mood:Affect:Thought Content:Thought Process:Cognition/Intelligence:Clinical Insight:Clinical Judgment:Significant Data/Contributing Dx/Labs/Misc.Plan:Differential Diagnoses1.2.Principal Diagnoses1.2.PlanDiagnosis #1Diagnostic Testing/Screening:Pharmacological Treatment:Non-Pharmacological Treatment:Education:Referrals:Follow-up:Anticipatory Guidance:Diagnosis #2Diagnostic Testingg/Screenin:Pharmacological Treatment:Non-Pharmacological Treatment:Education:Referrals:Follow-up:Anticipatory Guidance:Signature (with appropriate credentials): __________________________________________Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________DEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________Refill:_________________No SubstitutionSignature:____________________________________________________________Rev. 10162021 LMimage1.pngScreenshot2024-10-25at15.40.13.pngThis file is too large to display.View in new windowsoapnoterubric.docxThis file is too large to display.View in new windowsoapnotetemplate.docxPsychiatric SOAP Note TemplateEncounter date: ________________________Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____Reason for Seeking Health Care: ______________________________________________HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SI/HI:_______________________________________________________________________________Sleep:_________________________________________Appetite:________________________Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________Current perception of Health: Excellent Good Fair PoorPsychiatric History:Inpatient hospitalizations:DateHospitalDiagnosesLength of StayOutpatient psychiatric treatment:DateHospitalDiagnosesLength of StayDetox/Inpatient substance treatment:DateHospitalDiagnosesLength of StayHistory of suicide attempts and/or self injurious behaviors:____________________________________Past Medical History· Major/Chronic Illnesses____________________________________________________· Trauma/Injury ___________________________________________________________· Hospitalizations __________________________________________________________Past Surgical History___________________________________________________________Current psychotropic medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________Current prescription medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________OTC/Nutritionals/Herbal/Complementary therapy:_________________________________________ _________________________________________________________________________ ________________________________Substance use:(alcohol, marijuana, cocaine, caffeine, cigarettes)SubstanceAmountFrequencyLength of UseFamily Psychiatric History:_____________________________________________________Social HistoryLives: Single family House/Condo/ with stairs: ___________Marital Status:________Education:____________________________Employment Status: ______Current/Previous occupation type: _________________Exposure to:___Smoke____ ETOH ____Recreational Drug Use: __________________Sexual Orientation:_______ Sexual Activity: ____Contraception Use: ____________Family Composition:Family/Mother/Father/Alone: _____________________________Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________________________________________________________________________________Health MaintenanceScreening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____Exposures:Immunization HX:Review of Systems:General:HEENT:Neck:Lungs:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Activity & Exercise:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Physical ExamBP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____General:HEENT:Neck:Pulmonary:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Derm:Psychosocial:Misc.Mental Status ExamAppearance:Behavior:Speech:Mood:Affect:Thought Content:Thought Process:Cognition/Intelligence:Clinical Insight:Clinical Judgment:Significant Data/Contributing Dx/Labs/Misc.Plan:Differential Diagnoses1.2.Principal Diagnoses1.2.PlanDiagnosis #1Diagnostic Testing/Screening:Pharmacological Treatment:Non-Pharmacological Treatment:Education:Referrals:Follow-up:Anticipatory Guidance:Diagnosis #2Diagnostic Testingg/Screenin:Pharmacological Treatment:Non-Pharmacological Treatment:Education:Referrals:Follow-up:Anticipatory Guidance:Signature (with appropriate credentials): __________________________________________Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________DEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________Refill:_________________No SubstitutionSignature:____________________________________________________________Rev. 10162021 LMimage1.pngScreenshot2024-10-25at15.40.13.pngThis file is too large to display.View in new windowsoapnoterubric.docxThis file is too large to display.View in new window123Bids(65)Dr. Ellen RMEmily ClareDr. Sarah BlakeMISS HILLARY A+abdul_rehman_Prof Double RDoctor.NamiraSTELLAR GEEK A+Young NyanyaProWritingGuruProf. TOPGRADEgrA+de plusDr. Adeline Zoefirstclass tutorDr M. MichelleWIZARD_KIMDr. Sophie MilesnicohwilliamTutor Cyrus KenPremiumShow All Bidsother Questions(10)DeletedA random sample of 500 consumers in a certain country consistedWeb interface designEE CUMMINGS AND THE MODERN MANUnit II Essay Compose a 500-word point-of-view essay illustrating a chosen perspective of one of the figures listed below:  a citizen of Jamestown, VA during Bacon’s Rebellion,  a former indentured servant witnessing a slave auction,  a Spanish citizenDefine and explain the Three “E’s,” and comment on their significance in fire prevention. Give a practical example of eachDefinition Argument EssayPSY 870: Module 7 Problem SetExcel Worksheet 5–Math 243–Fall 2015Wide Area Networking Paper 500 words

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