Follow these guidelines for APA. This is maternity note ,please adapt to advance primary care References in APA have to be within a 5-year range. Make sure you include Psych History as well and also Genitourinary system. Patient Demographics Age: 24 years Race: Hispanic Gender: Male Insurance: No insurance Referral: No referral Clinical Information Time with Patient: 30 minutes Consult with Preceptor: 20 minutesType of Decision-Making:Low complexityReason for Visit:EpisodicChief Complaint:DysuriaType of HP:DetailedSocial Problems Addressed:Sanitation/Hygiene Safety Sexuality Prevention Procedures/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 SPECIFIED Medications # OTC Drugs taken regularly: 0# Prescriptions currently prescribed:0# New/Refilled Prescriptions This Visit:2Types of New/Refilled Prescriptions This Visit: Infectious Diseases Fluoroquinolones Infectious Diseases Urinary anti-infectives Other Questions About This Case Patients Primary Language:SpanishSmoking Assessment:Current SmokerAdvanced Directive:No Packs per day:
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