Description
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Miami Regional University (Acct #3111)
Case ID #: 4263-20240228-004 (Status: Pending)
Date of Encounter: 2/28/2024
Student Information – Shopsha, Oksana
Semester: Spring
Course: MSN5700C Advanced Practice in Primary Care I
Preceptor: RODRIGUEZ REYES, MARIA DE LOS A.
Clinical Site: Get Well Family Practice
Setting Type:
Patient Demographics
Age: 45 years
Biological Sex: Female
Race: White, Non Hispanic
Insurance: HMO or prepaid plan
Referral: No referral
Clinical Information
Time with Patient: 30 minutes
Consult with Preceptor:
Type of Decision-Making: Moderate complexity
Reason for Visit: Annual/Well-Person Exam
Chief Complaint: Patient is here for wellness exam, Patient reports feeling fast heartbeat
Type of HP: Comprehensive
Social Problems Addressed: Safety
Abused Child/Adult
Nutrition/Exercise
Palliative/End of Life Care
Procedures/Skills (Observed/Assisted/Performed) (Critical in Bold)
Physical Assessment – Physical Assessment (Perf)
General Skills – Vital Signs (Perf)
ICD-10 Diagnosis Codes
#1 – Z00.01 – ENCOUNTER FOR GENERAL ADULT MEDICAL EXAM W ABNORMAL FINDINGS
#2 – R00.02 is not a valid ICD code.
CPT Billing Codes
#1 – 99386 – INITIAL COMPREHENSIVE PREVENTIVE MEDICINE E&M W/HX/EXAM, NEW PT; 40-64 YR
Birth & Delivery
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Re lled Prescriptions This Visit: 0
Types of New/Re lled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Patient’s Primary Language: English
Smoking Assessment: Never
Advanced Directive:
Packs per day:
Clinical Notes
Mammogram ordered.
Pap smear.
Colonoscopy at 45 years old.
CBC, CMP, LIPID, TSH, U/A, VIT D level.
Ekg.
Cardiology consult , dermatology and gyn consult.
Return in 4-8 weeks or sooner PRN..
Advised to increase and maintain physical activity for physical and emotional health, as well as improvement of chronic illness. .
Encounter Continuity
Linked encounters:
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***Report generated 3/7/2024 4:34:40 PM CT***
Oksana Shopsha
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site: Maria Rodriguez Reyes/ Get Well Family Practice
Clinical Instructor: Alain Rojas
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
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)
•
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•
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Pharmacological treatment:
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
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