Use of APA 7th edition format and grammar
Identifying data, but only use the individual's initials
Chief Complaint (CC)
History of Present Illness (HPI)
Psychiatric History and Substance Use History
Personal and Social History
Mental Status Examination
Suicide and Homicide Assessment
Medical History
Allergies
Current Medications
Review of Systems
History of Abuse, Neglect, and Trauma
Mental Status Examination
Assessment i.e. DSM 5-TR Diagnosis
Nursing Theory/Psychodynamic Approach
Treatment Plan and Goals
Education and Referrals
Conclusions and Summary
References page including evidenced-based data
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- Note: TurnItIn will be linked with this assignment
- Topic: anxiety
- (The medical case must be of a patient diagnosed with anxiety)
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