Create 12 Geriatric ONLY Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new perspective in a clinic setting. Include a variety of preventive visits, chronic, and wellness disorders annual exam pertaining only to this population.Include developmental appropriate stages. Every soap note needs a diagnosis and therapeutic section must have medications and full prescribing instructions specifically for the geriatric population. .Include low to medium complexity in ICD code.
Documentation Requirements
Must Include
- Patient Demographics Section:
- Age
- Race
- Gender
- Clinical Information Section:
- Time with Patient
- o Reason for visit
- o Chief Complaint
- o Social Problems Addressed
- Medications Section:
- o # OTC Medications taken regularly
- o # Prescriptions currently prescribed
- o # New/Refilled Prescriptions This Visit
- ICD 10 Codes Category:
- o Include for each diagnosis addressed at the visit
- CPT Billing Codes Category:
- o Include Evaluation and management code
- o Provider procedure codes (pap smear, destruction of lesion, sutures, etc.)
- Other Questions About This Case Category:
- o Age Range
- o Patient type
- o HPI
- o Patients Primary Language
- o Did you chart on the patient record?
- o Discussed Management with the Preceptor Handled Visit Independently
- o Preceptor Present During Visit
Clinical Notes Category :
PLEASE follow this format
ChiefComplaint: “***”
DIAGNOSIS: must have
PLAN:
Diagnostics:
Therapeutics:include full prescribing information safe dosing
Education: Include (Developmental Stage guidance)
Consultation/Collaboration:
make sure the cpt /icd10 codes match the diagnosis
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