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.
Time with Patient:
Consult with Preceptor:
20 minutesType of Decision-Making:Low complexityReason for Visit:EpisodicChief Complaint:DysuriaType of HP:DetailedSocial Problems Addressed:Sanitation/Hygiene
Physical Assessment – Physical Assessment (Perf)
General Skills – Urine Analysis via dipstick (Perf)
General Skills – Vital Signs (Perf)
ICD-10 Diagnosis Codes#1 – N39.0 – URINARY TRACT INFECTION, SITE NOT SPECIFIED
# OTC Drugs taken regularly:
0# Prescriptions currently prescribed:0# New/Refilled Prescriptions This Visit:2Types of New/Refilled Prescriptions This Visit:
Infectious Diseases – Fluoroquinolones
Infectious Diseases – Urinary anti-infectives
Other Questions About This Case
Patient’s Primary Language:SpanishSmoking Assessment:Current SmokerAdvanced Directive:No
Packs per day:
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