Chronic Obstructive Pulmonary Disease Geriatric Soap Notes

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.

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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