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Pediatric Soap Notes from an FNP Perspective Paper

Pediatric Soap Notes from an FNP Perspective Paper

Pediatric Soap Notes from an FNP Perspective Paper

Create 12 PEDIATRIC ONLY (birth to 18 years old) Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new perspective. 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 pediatric population. Include the patient’s weight. 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 for pediatrics include weight
Education: Include (Developmental Stage guidance)

Consultation/Collaboration:

*** I will be uploading soap notes completed to avoid repeating diagnosis, it has to be non acute diagnosis that can be taken care of in a rural office

Pediatric Soap Notes from an FNP Perspective Paper

Pediatric Soap Notes from an FNP Perspective Paper

 

 

 

 

 

 

 

 

 

 

 

Pediatric Soap Notes

Student’s Name

Institutional Affiliation

 

 

Pediatric Soap Notes

  1. Respiratory Synctial Virus (RSV) Prophylaxis done
Patient Demographics

 
Age: 2 Race:  Hispanic Gender: Male
Clinical Information

 
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

 – 15 minutes

– preventive medicine

– RSV prevention

– behavioral

 
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          Palivizumab
ICD 10 Codes B97.4

 
CPT Billing Codes 1.      Evaluation and management

2.      Provider procedure codes

 –           99213, 1000F, 2000F, 3006F

–          97760
Other Questions

 
1.      Age range – toddler

2.      Patient type – outpatient

3.      HPI – hemodynamically significant congenital disease

4.      Patients primary language –  English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 
Clinical Notes

 
1.      Chief complaint – hemodynamically significant congenital disease

B.     Diagnosis – Respiratory Synctial Virus  (RSV) Prophylaxis

 

2.      Plan – Lungs exam

o   findings – wheezing and cough

3.      Diagnostic –  pulse oximetry

4.      Therapeutic – Palivizumab (synagis) 15 mg per kg IM q monthly all through winter

5.      Education –  wash hands before handling the child, keep surfaces disinfected, discourage sharing of utensils, and limit contact with those with cold-like symptoms

6.      Collaborated – collaborated with pediatrician during patient care

 

 

  1. Fifth disease (Parvovirus)
Patient Demographics

 
Age: 5 Race:  Non-Hispanic Gender: Female
Clinical Information

 
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed

 – 50 minutes

– problem focused

– facial rash and fever

– behavioral

 
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          Intravenous immunoglobulin (IVIG)
ICD 10 Codes B08.3

 
CPT Billing Codes 1.      Evaluation and management

2.      Provider procedure codes

 –          1000F, 2000F, 99222

–          86747
Other Questions

 
1.      Age range – preschooler

2.      Patient type – inpatient

3.      HPI – fever, upset stomach, headache, runny nose, facial rash

4.      Patients primary language – English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 
Clinical Notes

 
1.      Chief complaint – fever and facial rash

Diagnoses

2.      Plan – skin exam

o   findings – red cheeks and a red, lacy rash on the upper arms, legs, trunk, and buttocks

3.      Diagnostic –  blood test

4.      Therapeutic – 400mg/kg IV of commercial IVIG for 5 days

5.      Education – general parent and child hygiene and avoid sharing drinks and food.

6.      Collaborated – collaborated with pediatrician during patient care

 

 

 

  1. Croup donedone
Patient Demographics

 
Age: 4 Race:  African American Gender: female
Clinical Information

 
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

 – 30 minutes

– problem focused

– breathing problem

– behavioral

 
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          dexamethasone
ICD 10 Codes J05.0

 
CPT Billing Codes 1.      Evaluation and management

2.      Provider procedure codes

 –          1000F, 2000F, 99203

–          71035
Other Questions

 
1.      Age range – preschooler

2.      Patient type –  outpatient

3.      HPI – breathing sound, fever, hoarse voice, cyanosis, drooling, anxious and agitated

4.      Patients primary language – English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 
Clinical Notes

 
1.      Chief complaint – fever and difficulty in breathing

Diagnoses

2.      Plan – lung exam

o   findings – expiratory wheezing, inspiratory stridor, sternal wall retraction, intercostal and suprasternal indrawing

3.      Diagnostic –  chest x-ray

4.      Therapeutic – dexamethasone 0.60 mg/kg IV single dose

5.      Education –  encourage child to sneeze or cough into her elbow, keep child away from sick persons, observe hand hygiene

6.      Collaborated – collaborated with pediatrician during patient care

 

 

 

  1. Bullous Impetigo done
Patient Demographics

 
Age: 5 Race:  Caucasian Gender: Male
Clinical Information

 
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

 – 30 minutes

– problem focused

– skin sores

– behavioral
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          Vancomycin
ICD 10 Codes L01.03

 
CPT Billing Codes 1.      Evaluation and management

 

2.      Provider procedure codes

 –          1000F, 2000F, 3006F, 4000F,  99221

–          87070
Other Questions

 
1.      Age range – preschooler

2.      Patient type –  inpatient

3.      HPI – blisters occurring on the child’s body

4.      Patients primary language – English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 
Clinical Notes

 
1.      Chief complaint – blisters and sores

2.      Diagnosis – Bullous Impetigo

 

3.      Plan – skin exam

o   findings – ulcers that are punched out with raised borders

4.      Diagnostic –  culture

5.      Therapeutic – vancomycin 10 mg/kg iv q6h

6.      Education –  general hygiene, keep child’s nails short, keep child home until he is not contagious

7.      Collaborated – collaborated with pediatrician during child care

 

 

 

  1. Kawasaki Diseasedone
Patient Demographics

 
Age: 4 Race:  Pacific Islander Gender: Male
Clinical Information

 
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

 – 50 minutes

– problem focused

– high fever

– lifestyle

 
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          IVIG and Aspirin
ICD 10 Codes M30.3

 
CPT Billing Codes 1.      Evaluation and management

 

2.      Provider procedure codes

 –          1000F, 2000F, 3006F, 4000F, 99222

–          85027, 93010, 81000
Other Questions

 
1.      Age range –  Preschooler

2.      Patient type –  inpatient

3.      HPI – lymphadenopathy, conjunctivitis, fever, and red, dry, cracked lips

4.      Patients primary language – English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 
Clinical Notes

 
1.      Chief complaint – conjunctivitis and high fever

G.    Diagnosis- Kawasaki Disease

2.      Plan – physical exam

o   findings – skin erythema, edema, desquamation, rash, and beau lines

HEENT – lips fissures, conjunctiva injection, sensorineural hearing loss, strawberry tongue

Neck – neck stiffness, cervical lymphadenopathy

Abdomen- tenderness, hepatomegaly

Heart – tachycardia, arrhythmia

3.      Diagnostic –  urine test, white cell blood count, electrocardiogram,

4.      Therapeutic – IVIG 2g/kg single infusion and aspirin 80 mg/kg/day qid

5.      Education –  healthy living habits

6.      Collaborated – collaborated with pediatrician during child care
  1. Pertussis done
Patient Demographics

 
Age: 5 months Race:  African American Gender: female
Clinical Information

 
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

 – 30 minutes

– problem focused

– runny nose

– behavioral

 
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          Azithromycin
ICD 10 Codes A37.90

 
CPT Billing Codes 1.      Evaluation and management

2.      Provider procedure codes

 –          1000F, 2000F, 99203

–          85027, 87070
Other Questions

 
1.      Age range – infant

2.      Patient type –  outpatient

3.      HPI – runny nose, fever, nasal congestion, cough, watery eye

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 
Clinical Notes

 
1.      Chief complaint – fever and runny nose

Diagnosis-Pertussis

2.      Plan – lung exam

o   findings – lungs are clear with no signs of lower tract infection

3.      Diagnostic –  throat culture, white blood cell test

4.      Therapeutic – azithromycin 10 mg/kg PO qd 5 days

5.      Education –  general hygiene and lifestyle education

6.      Collaborated – collaborated with pediatricians during infant care

 

 

 

  1. Pneumonia done
Patient Demographics

 
Age: 5 days Race:  Hispanic white Gender: female
Clinical Information

 
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

 -70  minutes

– problem focused

– flu-like symptoms

– behavioral
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          Ampicillin and gentamicin
ICD 10 Codes J18.9

 
CPT Billing Codes 1.      Evaluation and management

2.      Provider procedure codes

 –          0001F, 1000F, 2000F, 99223

–          71035
Other Questions

 
1.      Age range – new born

2.      Patient type –  inpatient

3.      HPI – shortness of breath, fever, vomiting, cough

4.      Patients primary language – English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 
Clinical Notes

 
1.      Chief complaint – fever and cough

Diagnosis-Pneumonia

2.      Plan – lung exam

o   findings – increased tactile fremitus, dullness on percussion, decreased breath sounds, rhonchi, increased vocal fremitus, rales, and bronchial breath sounds

3.      Diagnostic –  chest x-ray

4.      Therapeutic –  gentamicin 5 mg/kg IM once daily for 5 days and  50mg/kg per dose amoxicillin for 7 days

5.      Educational – good hygiene to protect baby from respiratory infections and vaccination

6.      Collaboration- collaborated with pediatrician during child care

 

 

 

  1. Varicella Zoster done
Patient Demographics

 
Age: 13 years Race:  Caucasian Gender: female
Clinical Information

 
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

 – 30 minutes

– problem focused

–  papules on the skin

– behavioral

 
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          Acyclovir
ICD 10 Codes B02.9

 
CPT Billing Codes 1.      Evaluation and management

2.      Provider procedure codes

 –          0001F, 1000F, 2000F, 99203

–          11100, 85027
Other Questions

 
1.      Age range – adolescent

2.      Patient type –  outpatient

3.      HPI – fever, loss of appetite, headache, papules, vesicles and crusting

4.      Patients primary language –  English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 
Clinical Notes

 
1.      Chief complaint – papules, vesicles and crusts

K.    Diagnosis Varicella Zoster

 

2.      Plan –skin exam

o   findings – parlor, skin lesions spreading all over the body forming papules that form vesicles and crust , oral ulcers, lymphadenopathy, organomegaly,

3.      Diagnostic –  blood test, skin lesion culture

4.      Therapeutic – acyclovir 20 mg/kg q6h 5 days

5.      Education –  general behavioral education

6.      Collaborated – collaborated with pediatrician during patient care

 

 

 

  1. Diarrhea and Vomiting done
Patient Demographics

 
Age: 6 years Race:  non-Hispanic white Gender: male
Clinical Information

 
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

 – 45 minutes

– problem focused

– diarrhea and vomiting

– Behavioral

 
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          ORS – enfalyte
ICD 10 Codes A08.0

 
CPT Billing Codes 1.      Evaluation and management

2.      Provider procedure codes

 –          0001F, 1000F, 2000F, 99204

–          87045
Other Questions

 
1.      Age range – school-aged

2.      Patient type –  outpatient

3.      HPI – fever, episodes of vomiting, diarrhea, tarry stool,

4.      Patients primary language – English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 
Clinical Notes

 
1.      Chief complaint – diarrhea and vomiting

Diagnosis-Diarrhea and vomiting

2.      Plan – abdominal exam

o   findings – crams and tenderness

3.      Diagnostic –  stool test

4.      Therapeutic – oral rehydration solution – enfalyte

5.      Education –  general hygiene and high fluid intake

6.      Collaborated – collaborated with pediatrician during child care

 

 

 

  1. Swimmers Ear done
Patient Demographics

 
Age: 10 year Race:  African American Gender: Female
Clinical Information

Pediatric Soap Notes from an FNP Perspective Paper
1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

 – 30 minutes

– problem focused

– ear pain

– lifestyle

 
Medications

 
1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 –          None

–          None

–          Acetaminophen
ICD 10 Codes H60.332

 
CPT Billing Codes 1.      Evaluation and management

2.      Provider procedure codes

 –          2000F, 99203

–          92567, 92567
Other Questions

 
1.      Age range – school aged

2.      Patient type –  outpatient

3.      HPI – ear popping, ear pain, rubbing ears, fever, headache

4.      Patients primary language – English

5.      Chart on patient record –  no

6.      Discussed management with the preceptor handled visit independently –  no

7.      Preceptor present during visit –  no

 
Clinical Notes

 
1.      Chief complaint – ear pain

Diagnosis -swimmers ear

2.      Plan – ear exam

o   findings – stenosis of ear canal, granulation tissue, erythema, tenderness of the auricle and tragus, and otorrhea

3.      Diagnostic –  otoscopy and tympanometry

4.      Therapeutic – acetic acid 2.0% and hydrocortisone 1.0% TOP tid for 7dyas

5.      Education –  avoid aggressive cleaning of the ear can with cotton swabs

6.      Collaborated – collaborated with ENT pediatrician during patient care

Pediatric Soap Notes from an FNP Perspective Paper

 

 

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