Reference no: EM133927491

Question: Use this template for Comprehensive Notes (H&Ps) and Problem-Focused Notes (Episodic/progress notes). For the Problem-Focused Notes, only include pertinent problem-focused information related to the chief concern (CC). Get the best assignment help from our pro-writers.

Patient is a 53 year old female who comes in with complains of feeling depressed. Patient verbalizes lack of energy and not wanting to go out in public. These symptoms started about 3 weeks ago. She denies any history of depression. She is currently in menopause state. She denies any suicide ideations. Patient poorly dress and well nourished. Focused physical assessment performed. No abnormal findings
Tx; Sertraline 25mg PO daily for 3 months
F/U in 4 weeks or PRN
Patient provided with hotline number in case of suicidal ideations

Demographic Data
o Patient age and gender identity
o MUST BE HIPAA compliant
Subjective
Chief Complaint (CC)
O Place the complaint in Quotes
O Brief description -only a few words and in the patient's words ... "My chest hurts," "I cannot breath," or "I passed out," etc.
History of Present Illness (HPI) - the reason for the appointment today
O Use the OLD CARTS acronym to document the eight elements of a chief concern (CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity)
O Briefly describe the general state of health prior to the problem.
O Are Activities of Daily Living (ADL) impacted by the current problem?

PAST MEDICAL HISTORY:
O List current and past medical diagnoses

PAST SURGICAL HISTORY:
O List all past surgeries

FAMILY HISTORY:
O Include medical/psychiatric problems to include 3 generations (parents, grandparents, siblings, or direct relatives.

CURRENT MEDICATIONS:
O Include current prescription(s), over-the-counter medications, herbal/alternative medications as well as vitamin/supplement use.

ALLERGIES: Include medications, foods, and chemicals such as latex.

IMMUNIZATIONS HISTORY: list current immunization status and address deficiency

PREVENTATIVE HEALTH HISTORY: (See Table below -Appendix A)
SOCIAL HISTORY:
O Include nutrition, exercise, substance use (details of use: caffeine, EtOH, illicit drug use), sexual history/preference, financial problems, legal issues, kids, and history of abuse, including sexual, emotional, or physical.
O Employment/Education: occupation (type), exposure to harmful agents, highest school achievement

REVIEW OF SYSTEMS:
O A ROS is a question-seeking inventory by body systems to identify signs and/or symptoms that the patient may be experiencing or has experienced that may or may not correlate with the CC.
*If a + finding is found not related to the cc this may represent an additional problem that will need to be detailed in the HPI.
O Must include any physical complaint(s) by the body system that is relevant to the treatment and management of the current concern(s). List only the pertinent body systems specific to the CC.
O Remember to include pertinent positive and negative findings when detailing the ROS related to a chief concern (cc).
O Do not repeat the information provided in HPI
O Use the format below when detailing the ROS