Chronic Obstructive Pulmonary Disease Geriatric Soap Notes
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 Assessment 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
