Posted: April 14th, 2022

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

(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 evaluation/HPI:
The affected person is …

Evaluation 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 Evaluation (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 evaluation/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

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