Patient Encounter Log Assignment Discussion Paper

A. 12 Pages —Develop a log of patient encounters You must record at least 80 encounters with patients (40 children/adolescents and 40 adult/older adult).

The patient log must include the following: Client Information
Visit Information
Practice Management
Diagnosis
Treatment Plan and Notes: You must include a brief summary/synopsis of the patient visit. This does not need to be a SOAP note, however the note needs to be sufficient to remember your patient encounter. Patient Encounter Log Assignment Discussion Paper

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See below for Sample ( Even if they are not as detailed as shown try and include as many clinical components as possible).
Ex: 23yo single female presents for a medication mgt visit. Dx: MDD, recurrent, moderate. Started on Zoloft 25mg daily 4 weeks ago, no adverse side effects, PHQ-9: 15 (was 20 on 11/1/21). Continues to feel depressed, sleep and appetite both good, no SI. MSE: mood is “depressed”, affect is constricted, a&o, dressed appropriately for weather, is heavily tattooed on her arms and neck, eye contact good, insight is fair. Will titrate Zoloft to 50mg to target mood, RTC 3 weeks, continue therapy. Patient Encounter Log Assignment Discussion Paper