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
  • ï‚· Clinical Information Section:
  • Time with Patient
  • o Reason for visit
  • o Chief Complaint
  • o Social Problems Addressed
  • ï‚· Medications Section:
  • o # OTC Medications taken regularly
  • o # Prescriptions currently prescribed
  • o # New/Refilled Prescriptions This Visit
  • ï‚· ICD 10 Codes Category:
  • o Include for each diagnosis addressed at the visit
  • ï‚· CPT Billing Codes Category:
  • o Include Evaluation and management code
  • o Provider procedure codes (pap smear, destruction of lesion, sutures, etc.)
  • ï‚· 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

ï‚· 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