MR soap week 4
years
Biological Sex:
Male
Race:
White, Non Hispanic
Clinical Information
Time with Patient:
30 minutes
Consult with Preceptor:
15 minutes
Type of Decision-Making:
Moderate complexity
Student Participation:
Shared (50-50)
Reason for Visit:
Follow-up (Routine)
Chief Complaint:
major depressive disorder
Social Problems Addressed:
Safety
Role Change
Procedures/Skills (Observed/Assisted/Performed) (Critical in Bold)
General Skills – Calculate BMI (Perf)
General Skills – Measurement of height (Perf)
General Skills – Wellness/health maintenance coaching (Perf)
ICD-10 Diagnosis Codes
#1 – f32.9 – MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED