January 24, 2023
week 8 discussion
January 24, 2023

Soap note UTI

Follow these guidelines for APA. This is maternity note ,please adapt to advance primary careReferences in APA have to be within a 5-year range.Make sure you include Psych History as well and also Genitourinary system.Patient DemographicsAge:24 yearsRace:HispanicGender:MaleInsurance:No insuranceReferral:No referralClinical InformationTime with Patient:30 minutesConsult with Preceptor:20 minutesType of Decision-Making:Low complexityReason for Visit:EpisodicChief Complaint:DysuriaType of HP:DetailedSocial Problems Addressed:Sanitation/HygieneSafetySexualityPreventionProcedures/Skills (Observed/Assisted/Performed)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 SPECIFIEDMedications# OTC Drugs taken regularly:0# Prescriptions currently prescribed:0# New/Refilled Prescriptions This Visit:2Types of New/Refilled Prescriptions This Visit:Infectious Diseases – FluoroquinolonesInfectious Diseases – Urinary anti-infectivesOther Questions About This CasePatient’s Primary Language:SpanishSmoking Assessment:Current SmokerAdvanced Directive:NoPacks per day:

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