Report Filters:
Report Calendar Year: 2019
Selected User(s): Scott, Dorothy
Selected Course(s): NR511: Differential Diagnosis and Primary Care Practicum(10871)
Selected Session(s): May 2019
Selected Status: Accepted
Page: 1
,Scott, Dorothy
Course Name: NR511: Differential Diagnosis and Clinical Site: Affordable Quality Care Patient Initials: EC
Primary Care Practicum (10871)
Log Date: 05/07/2019 Age Range: 1-4 years
Course Section: Section- 0
Last Updated: 05/29/2019 Gender: Male
Course Session: May 2019
Minutes: 00:25 Ethnicity: Hispanic or Latino
Faculty: Washington, Cynthia
Date Of Clinical: 05/07/2019 Client Complexity: Episodic (Acute Condition)
Preceptor: Williamson, Danny
Student Level of Function: 25% Student/75% Preceptor Type of Diagnostics: N/A Education Comments: Medication Management of OTC
meds
Type of Site: Family Medicine Ordering Diagnostics: N/A
Referrals: N/A
Type of Visit: Acute / Episodic Care Procedures:
Follow-up: 1 month
Physical Exam: Cardiac, Constitutional / Vital Medications: N/A
Signs, Heent, Medical
Therapeutics: Medication management,
Reconciliation, Respiratory
Nutrition therapeutics
99213 Establish level 3 visit
Tx: continue taking OTC tylenol and ibuprofen
Educated: Take OTC tylenol and ibuprofen for fever and can alternate. Use as directed on the label. Humidifier to help with the thicken mucus and drink plenty of fluids to
prevent dehydration and signs to look for dehydration.
Page: 2
,Scott, Dorothy
Course Name: NR511: Differential Diagnosis and Clinical Site: Affordable Quality Care Patient Initials: JR
Primary Care Practicum (10871)
Log Date: 05/07/2019 Age Range: 5-11 years
Course Section: Section- 0
Last Updated: 05/29/2019 Gender: Female
Course Session: May 2019
Minutes: 00:25 Ethnicity: Hispanic or Latino
Faculty: Washington, Cynthia
Date Of Clinical: 05/07/2019 Client Complexity: Episodic (Acute Condition)
Preceptor: Williamson, Danny
Student Level of Function: 25% Student/75% Preceptor Type of Diagnostics: N/A Education Comments: Antibiotic administration
Type of Site: Family Medicine Ordering Diagnostics: N/A Referrals: N/A
Type of Visit: Acute / Episodic Care Procedures: Follow-up: 3 months
Coding: -Other specified local infections of the skin and subcutaneous tissue
Skills & Procedures: N/A
Notes:
99213 Established level 3 visit
TX: prescribe prednisone and itraconazole
Education: apply to affected area until it is all gone. Wash hands w/soap and warm water. Take prednisone w/food and plenty of fluids.
Page: 3
, Scott, Dorothy
Course Name: NR511: Differential Diagnosis and Clinical Site: Affordable Quality Care Patient Initials: EN
Primary Care Practicum (10871)
Log Date: 05/07/2019 Age Range: 5-11 years
Course Section: Section- 0
Last Updated: 05/29/2019 Gender: Female
Course Session: May 2019
Minutes: 00:30 Ethnicity: Hispanic or Latino
Faculty: Washington, Cynthia
Date Of Clinical: 05/07/2019 Client Complexity: Episodic (Acute Condition)
Preceptor: Williamson, Danny
Student Level of Function: 25% Student/75% Preceptor Type of Diagnostics: N/A Education Comments: Antibiotic Administration
Type of Site: Family Medicine Ordering Diagnostics: N/A Referrals: N/A
Type of Visit: Acute / Episodic Care Procedures: Follow-up: 3 months
Coding: -Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
Skills & Procedures: N/A
Notes:
99214 Established level 4 visit
Tx: prescribe Ciprodex
Education: instructed to distill 1-2 drops in affected ear until drops are all gone. Do not discontinue even if affected ear starts to feel better.
Page: 4
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