PMH: HTN, Hyperlipidemia
Social History: divorced, employed full time as a graduate nursing program professor, no smoking history, reports on a rare occasion she may have a 2 – 3 ounces of wine when dining out [less than 6 times a year]
Health Maintenance Activities: 1 ½ to 2 hours of exercise every morning [45 60 minutes of yoga, 45 60 minutes of step aerobics]; low glycemic Pescatarian; has not engaged with recommended colonoscopy, does not have screening mammograms, does not get a flu shot and has not had any other recommended adult immunizations
Utilize the information provided in the scenario to create your discussion post.
Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
Structure your P in the following format:
Therapeutics: pharmacologic interventions, if any new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative)
Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the therapeutics identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
Consultation/Collaboration: if appropriate – collaborative Advanced Care Planning with the patient/patients care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
