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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
Patient’s Primary Language:SpanishSmoking Assessment:Current SmokerAdvanced Directive:No
Packs per day:

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