Date of Encounter:Preceptor/Clinical Site:Clinical Instructor: Patricio Bidart MSN, APRN, FNP-CSoap Note # _2___ Main Diagnosis ___hepatic encephalopathy___________PATIENT INFORMATIONName:Age:Gender at Birth:Gender Identity:Source:Allergies:Current Medications:·PMH:Immunizations:Preventive Care:Surgical History:Family History:Social History:Sexual Orientation:Nutrition History:Subjective Data:Chief Complaint:Symptom analysis/HPI:The patient is Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states .. )CONSTITUTIONAL:NEUROLOGIC:HEENT:RESPIRATORY:CARDIOVASCULAR:GASTROINTESTINAL:GENITOURINARY:MUSCULOSKELETAL:SKIN:Objective Data:VITAL SIGNS:GENERAL APPREARANCE:NEUROLOGIC:HEENT:CARDIOVASCULAR:RESPIRATORY:GASTROINTESTINAL:MUSKULOSKELETAL:INTEGUMENTARY:ASSESSMENT:(In a paragraph please state your encounter with your patient and your findings ( including subjective and objective data)Example : Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc on examination I noted this and that etc.)Main Diagnosis(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.Differential diagnosis (minimum 3)—PLAN:Labs and Diagnostic Test to be ordered (if applicable)· -· -Pharmacological treatment:-Non-Pharmacologic treatment:Education (provide the most relevant ones tailored to your patient)Follow-ups/ReferralsReferences (in APA Style)ExamplesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010(25th ed.). Print (The 5-Minute Consult Series).Use APA format and must include minimum of 2 Scholarly Citations.
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