NURS 612

O.A.P. Note Template CASE ID# Tina Jones- Mental Health S.O.A.P. Note TemplatCASE ID# Tina Jones- Mental Health Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan) What brought you here today… (eg. headache) Difficulty sleeping History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Ms. Jones pre...

ADVANCED HEALTH ASSESSMENT Health History - TINA JONES™ © Shadow Health® || ShadowH **For instructor use only** Page 1 of 3 Instructor Use Only Ms. Jones is a pleasant, 28 -year- old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones off ers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the intervi...