Running head: GERIATRIC SOAP NOTES
Geriatric Soap Notes
Student’s Name
Institutional Affiliation
1
GERIATRIC SOAP NOTES
2
Geriatric Soap Notes
A. Chronic Obstructive Pulmonary Disease (COPD)
Patient Demographics
Age: 70
1.
2.
3.
4.
Race: non-Hispanic white
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 15 minutes
- Problem focused visit
- Chest tightness
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
Gender: Male
•
•
•
None
None
Aclidinium, nicorette
J44.9
1. Evaluation and management
2. Provider procedure codes
•
•
99213
94010, 82850
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – shortness of breath, having to clear throat every morning, lack of energy,
productive cough, active smoker (half packet per day), COPD
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 – chest tightness
Diagnoses
2. Plan – lung exam
• Findings – wheezing, cyanosis, tachypnea, hyperinflation, hyperresonance,
coarse crackle with inspiration, diffusely decreased breath sounds
3. Diagnostic – pulmonary function test (spirometry), arterial blood gas analysis
4. Therapeutic – aclidinium 400 mcg inhaled PO BID
• Nicorette 2mg oral chewing gum for 2 weeks
5. Educational – smoking cessation and general healthy lifestyle, including diet and
exercise
6. Collaboration – collaborated with pulmonologist during patient care.
GERIATRIC SOAP NOTES
3
B. Emphysema
Patient Demographics
Age: 65
1.
2.
3.
4.
Race: Hispanic white
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Shortness of breath
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
Gender: female
•
•
•
None
None
aclidinium
J43.9
1. Evaluation and management
2. Provider procedure codes
•
•
99202
71260, 94010
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range –older adult
Patient type – outpatient
HPI – shortness of breath and inability to do tasks like taking a flight of stairs
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - shortness of breath
Diagnoses
2. Plan – pulmonary exam
• Findings – pink puffers, barrel chest, respiratory distress indicated by use of
accessory respiratory muscles, hyperresonance, prolonged expiration, coarse
crackle with inspiration, diffusely decreased breath sound
3. Diagnostic – chest CT-scan, lung function test,
7. Therapeutic - aclidinium 400 mcg inhaled PO BID
• Pulmonary rehabilitation
4. Education – proper nutrition to prevent weight loss, avoid respiratory irritants, prevent
respiratory infection through immunization, and regular exercise.
5. Collaboration – collaborated with
GERIATRIC SOAP NOTES
4
C. Obesity and Health Risk Screening
Patient Demographics
Age: 66
Race: White
Gender: female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 15 minutes
- Wellness visit
- Weight gain
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
-
None
None
No medication prescribed
Z71.3
1. Evaluation and management
2. Provider procedure codes
-
2000F, 99401
83718, 10256, 82947, 80091
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – weight gain
Patients primary language – English
Chart on patient record – no
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - weight gain
Diagnosis
2. Plan – BMI calculation, waist circumference
• Findings - BMI of 30, central obesity (40 inches)
3. Diagnostics – cholesterol test, liver function test, fasting glucose test, thyroid test
4. Therapeutics – no medication prescribed
- Exercise regime
5. Educational – exercise, nutritional adjustment to limit carbohydrates and increase lean
protein and vegetables, and alcohol cessation
6. Consultations – consulted nutritional doctor during patient education
GERIATRIC SOAP NOTES
5
D. Cellulitis
Patient Demographics
Age: 68
Race: Hispanic
Gender: male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 15 minutes
- Problem-focused visit
- Painful skin rush on the left leg
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
•
•
•
None
Lamivudine
cephalexin
L03.116
1. Evaluation and management
2. Provider procedure codes
•
•
99213
87077, 86361
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – fatigue, fever, sweating, nausea and vomiting, numbness of affected region,
HIV, obesity
4. Patients primary language – English
5. Chart on patient record – no
6. Discussed management with the preceptor handled visit independently – yes
7. Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - painful skin rush
Diagnosis
2. Plan – skin assessment
• Findings – red, warm, swollen skin on the left leg
3. Diagnostic – blood test, T-cells absolute CD4 count
4. Therapeutic – oral cephalexin 500mg q6h x 5 for 10 days
• Care – good hygiene, cleaning, and dressing of the wound
5. Educational – nutritional education to control obesity
6. Collaboration – collaborated with dermatologist during patient care
GERIATRIC SOAP NOTES
6
E. Asthma
Patient Demographics
Age: 66
Race: White
Gender: female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Wellness visit
- breathlessness
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes J45.909
CPT Billing
Codes
1.
2.
3.
4.
5.
6.
7.
-
None
albuterol
albuterol
1. Evaluation and management 2. Provider procedure codes
Other Questions
99212
94010, 94150
Age range – older adult
Patient type – outpatient
HPI – asthmatic, exacerbation
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - breathlessness
Diagnoses
2. Plan – respiratory assessment
• Findings – absence of transverse crease, pro-longed end expiratory wheeze
3. Diagnostics – spirometry and peak flow test
4. Therapeutics – nebulization and albuterol q6h
5. Education – avoid cigarette smoke, avoid intense physical activity, and avoid allergens
including fumes, pets, and dust
6. Collaboration – collaborated with pulmonologist during patient care
GERIATRIC SOAP NOTES
7
F. Ulcerative Colitis
Patient Demographics
Age: 65
Race: Dutch
Gender: Female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem-focused visit
- Abdominal pain
- Behavioral
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- Mesalamine
ICD 10 Codes
K51.919
CPT Billing Codes
1. Evaluation and management
2. Provider procedure codes
-
99202
36415, 82270, 45378,
45330
Other Questions
1. Age range – elderly
2. Patient type – outpatient
3. HPI – mucoid bloody diarrhea of gradual onset, rectal urgency, blood on inner wear,
weight loss, tenesmus
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 – pain in the abdomen
Diagnoses
2. Plan – gastrointestinal assessment
• Findings – absence of tenderness indicating less severe disorder, blood seen
on rectal exam
3. Diagnostic - blood test, stool test, colonoscopy, flexible sigmoidoscopy
4. Therapeutic – Mesalamine 1.5g tid for 2.4 weeks
5. Educational – avoidance of spicy foods and reduction high fiber foods, consume high
protein and high-calorie foods low in fiber
6. Collaboration – collaborated with gastroenterologist during patient care
GERIATRIC SOAP NOTES
8
G. Adrenal Insufficiency
Age: 68
1.
2.
3.
4.
Patient Demographics
Race: non-Hispanic white
Gender: female
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 30 minutes
- Problem-focused evaluation
- Extreme fatigue
- behavioral change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
Oral rehydration solution
None
Hydrocortisone
E27.1
1. Evaluation and management
2. Provider procedure codes
-
99203
36415, 80400, 82951,
74150
Other Questions
1. Age range - Older adult
2. Patient type – outpatient
3. HPI – nausea, dizziness, depression, anorexia, extreme fatigue, salt craving, sexual
dysfunction, fainting, and joints and muscle pain
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 – extreme fatigue
Diagnosis
2. Plan – clinical evaluation
• Findings – hyperpigmentation, irritability, orthostatic hypotension, fever
3. Diagnostics – blood test, adrenocorticotropic stimulation test, insulin-induced
hypoglycemia test, abdomen and neck adrenal glands CT scan
4. Therapeutic – Hydrocortisone 100 mg bolus immediately; followed by e100 mg q8h
oral maintenance dose 10mg morning, 5mg noon, and 5mg afternoon
5. Educational – general healthy living habits, including proper nutrition, exercise, and
preventive medicine
6. Consultation – collaborated with endocrinologist during patient care.
GERIATRIC SOAP NOTES
9
H. Colon Cancer Screening
Patient Demographics
Age: 69
1.
2.
3.
4.
Race: African American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Preventive visit
- No presenting complaint
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
Gender: Male
-
None
Prednisone
None
Z12.11
1. Evaluation and management
2. Provider procedure codes
-
99201
45378
Other Questions
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
4.
5.
6.
Age range - elderly adult
Patient type – outpatient
HPI – Crohn’s disease
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
Chief complaint – no presenting complaints
Diagnoses
Plan– abdominal assessment
• Findings – no ascites, absence of mass, no hepatomegaly, no rectal bleeding
Diagnostic – colonoscopy
Therapeutic – no medication prescribed
Education – immunizations, nutritional education including consumption of high fiber
foods and general healthy lifestyle including physical exercise and limitation of alcohol
use
Collaboration – collaborated with gastroenterologist during screening
GERIATRIC SOAP NOTES
I. Influenza
Patient Demographics
Age: 72
Race: African American
Gender: Female
Clinical Information
1. Time with patient
- 10 minutes
2. Reason for visit
- Problem-focused visit
3. Chief complaint
- Fever and headache
4. Social problems addressed
- Lifestyle
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- Oseltamivir
ICD 10 Codes
J11.1
CPT Billing
1. Evaluation and management
- 99201
Codes
2. Provider procedure codes
- 87804
Other Questions
1. Age range - older adult
2. Patient type – outpatient
3. HPI - Nasal congestion, fever, fatigue, sore throat, sweats and chills, and muscle ache
that began 4-days ago
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 headache
Diagnosis
2. Plan – upper respiratory evaluation
• Findings- nasal congestion, runny nose, throat erythema, dry cough,
focal wheezing, rales
3. Diagnostic – rapid flu test
4. Therapeutic - Oseltamivir 75 mg (1x2) for 5 days
5. Educational – geriatric immunization, general healthy living including moderate
exercise, stress reduction, and proper nutrition
6. Consultation – consulted with pulmonologist during patient management
10
GERIATRIC SOAP NOTES
11
J. Hemorrhoids
Patient Demographics
Age: 73
Race: Biracial
Gender: male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem-focused visit
- Anal irritation
- Nutritional change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
-
None
None
No drug prescribed
K64.8
1. Evaluation and management
2. Provider procedure codes
Other Questions
-
99202
46600
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI –discomfort in the anus associated with painful swelling, bleeding when passing
stool, and itching
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 – anal irritation
Diagnosis
2. Plan – anal evaluation
• Findings - skin tags in the anal verge
3. Diagnostic – anoscopy
4. Therapeutic - sitz baths : sit in warm water for 15 minutes q8 for 4 weeks AND cold
compresses
5. Educational - dietary change to a diet high in fiber and ensuring proper hydration to
avert constipation
6. Consultation – consulted with gastroenterologist during patient evaluation
GERIATRIC SOAP NOTES
12
K. Hepatitis C Test
Patient Demographics
Race: African American
Gender: male
Clinical Information
Age: 65
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 5 minutes
- Wellness visit
- No presenting complaint
- Behavioral change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
Abacavir
Abacavir
Z11.59
1. Evaluation and management
2. Provider procedure codes
-
99211
87522
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – HIV infection
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint – no presenting complaint
Diagnoses
2. Plan – clinical evaluation
Findings – no thyroid abnormalities, no hepatomegaly, no spider angioma, no palmar
erythema
3. Diagnostic – blood test for hepatitis C virus (HCV)
4. Therapeutic – Abacavir 1 tablet PO per day
5. Educational – good dietary habits, exercise, safe sex practices, importance of
immunization
6. Consultation – collaborated with gastroenterologist during patient assessment
GERIATRIC SOAP NOTES
13
L. Deep Vein Thrombosis
Patient Demographics
Age: 69
1.
2.
3.
4.
Race: Pacific Islander
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 30 minutes
- Problem focused
- Warmth in the leg
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
Gender: female
-
Ibuprofen
None
Fondaparinux
L82.402
1. Evaluation and management
2. Provider procedure codes
-
99203
85379, 93970
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range –older adult
Patient type – outpatient
HPI – cramping in the calf, warmth in the leg
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint – warmth in the leg
Diagnoses
2. Plan – lower extremity assessment
• Findings – unilateral calf redness, pitting edema, calf swelling, palpable
cord, localized tenderness of posterior calf, dilated unilateral collateral
superficial veins
3. Diagnostic – D dimer blood test, ultrasound
4. Therapeutic – fondaparinux 7.5 mg once daily
- Compression stockings
5. Education – regular exercise, avoid prolonged sitting or standing
6. Collaboration – collaborated with vascular doctor during patient care
Running head: GERIATRIC SOAP NOTES
Geriatric Soap Notes
Student’s Name
Institutional Affiliation
1
GERIATRIC SOAP NOTES
2
Geriatric Soap Notes
A. Shingles 9/21done
Patient Demographics
Age: 80
1.
2.
3.
4.
Race: Hispanic white
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 30 minutes
- Problem-focused visit
- Rash
- lifestyle change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
Gender: Male
-
None
Ibuprofen
Acyclovir
B02.9
1. Evaluation and management
2. Provider procedure codes
-
99203
86787
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI – pain and burning, red rash, itching, fluid-filled blisters that break open and
crust, sensitivity to touch
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 – itching rash
Diagnoses
2. Plan – skin evaluation
• Findings – unilateral rash affecting the neck and chest
3. Diagnostic – serology (varicella-zooster virus antibody)
4. Therapeutic – acyclovir 500 mg PO five times a day for 10 days
- Take cool bath and wet compresses on the blisters to relieve itching and pain
5. Educational – shingles vaccination and general healthy lifestyle habits
6. Collaboration – collaborated with serologist during patient management
GERIATRIC SOAP NOTES
3
B. Pneumococcal Vaccination 9/21done
Patient Demographics
Age: 71
1.
2.
3.
4.
Race: Hispanic white
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Preventive medicine
- None
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
Gender: female
-
None
None
Pneumococcal vaccine (PCV13)
V03.82
1. Evaluation and management
2. Provider procedure codes
-
99201
85027, 83036, 90670
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range –older adult
Patient type – outpatient
HPI – none
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - no presenting symptom
Diagnoses
2. Plan – clinical evaluation
• Findings – no crackles, no wheezing, no chest pain, no abdominal tenderness,
no rash, no hearing loss, myopic eyes with correction glasses, no incontinence
3. Diagnostic – complete blood counts, A1C test
Screening results – A1C test result: 5.6 percent, CBC results within normal range
4. Therapeutic - 13-valent pneumococcal vaccine
5. Education – general healthy living including diet and physical activity and importance
of immunization
6. Collaboration – collaborated with geriatrician during care
GERIATRIC SOAP NOTES
C. Human Immunodeficiency Virus Infection 9/21done
Patient Demographics
Age: 65
Race: African American
Gender: male
Clinical Information
1. Time with patient
- 10 minutes
2. Reason for visit
- Wellness visit
3. Chief complaint
- No presenting complaint
4. Social problems addressed
- behavioral change
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- Lamivudine
3. New/refilled prescriptions
- Lamivudine
ICD 10 Codes
Z71.7
CPT Billing
1. Evaluation and management
- 99212
Codes
2. Provider procedure codes
- 86360
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI – HIV positive
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
1.
2.
3.
4.
5.
6.
Clinical Notes
Chief complaint - no presenting symptom
Diagnosis
Plan – clinical evaluation
• Findings – no retinal hemorrhage, no hypotension, no fever, no skin lesions, no
oral thrush, no crackles and rhonchi, no abdominal tenderness, no joint swelling
Diagnostics – CD4 count
Therapeutic: Lamivudine 300mg once daily
Educational: proper nutrition, adherence to medication, ample rest, and physical
activity
Collaboration – collaborated with nutritionist during patient management
4
GERIATRIC SOAP NOTES
5
D. Glaucoma 9/21done
Patient Demographics
Age: 68
Race: Hispanic
Gender: male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
Medications
20 minutes
Eye wellness visit
None
Behavioral
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
Latanoprost eye drop
H40.11
1. Evaluation and management
2. Provider procedure codes
-
99202
92100, 92083, 76514,
92020
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – young adult
Patient type – outpatient
HPI – glaucoma screening
Patients primary language – English
Chart on patient record – no
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - none
Diagnosis
2. Plan – eye exam
• Findings - blind spots, visual field defects, notching of the rim, thinning of the
neurosensory rim
3. Diagnostic – tonometry, visual field test, pachymetry, and gonioscopy
4. Therapeutic – Latanoprost eye drop 0.005%, QD
5. Educational – adherence to medication prescription, safe regular exercise, wear eye
protection, and get regular dilated eye examinations
6. Collaboration – collaborated with ophthalmologist during patient evaluation
GERIATRIC SOAP NOTES
6
E. Lung Cancer Screening 9/21done
Patient Demographics
Age: 65
Race: White
Gender: female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Wellness visit
- None
- Behavioral change
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- Varenicline
ICD 10 Codes Z12.2
CPT Billing
1. Evaluation and management - 99201
Codes
2. Provider procedure codes
- 71250
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – older adult
Patient type – out
HPI – breathlessness, smoking
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - shortness of breath
Diagnoses
2. Plan – lung exam
• Findings – no tachypnea, no lymphadenopathy, no rounded face, normal
breathing sound, no dyspnea
3. Diagnostics – low-dose computed tomography
- Results – negative lung cancer
4. Therapeutics – smoking addiction therapy
- varenicline 0.5 mg/day q3days followed by 0.5 mg bid q4dyas, then 1mg bid
q6months
5. Education – smoking cessation and general healthy living
6. Consultation – managed patient in consultation with pulmonologist
GERIATRIC SOAP NOTES
7
F. Gastroesophageal Reflux Disease (GERD)9/21done
Patient Demographics
Age: 82
Race: Dutch
Gender: Female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
Medications
30 minutes
Problem focused
Heartburn
Lifestyle
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- aluminum hydroxide
ICD 10 Codes
K21.9
CPT Billing Codes
1. Evaluation and management - 99203
2. Provider procedure codes
- 43235
Other Questions
1. Age range – elderly
2. Patient type – outpatient
3. HPI – difficulty swallowing, sensation of a lump in the throat, regurgitation of sour
liquid, disrupted sleep, pregnancy
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 – patient presents at the office complaining of a burning sensation in
the chest.
Diagnoses
2. Plan – GIT evaluation
• Findings – epigastric tenderness, wheezing, hoarseness
3. Diagnostic - upper endoscopy
4. Therapeutic –antacid aluminum hydroxide 640 mg PO 6 times a day after meals and at
bed time.
5. Educational – healthy eating habits, eat at least 3 hours before going to bed, regular
exercise
6. Collaboration – collaborated with gastroenterologist during patient care
GERIATRIC SOAP NOTES
8
G. Diabetic Retinopathy Screening 9/21done
Patient Demographics
Age: 68
Race: non-Hispanic white
Gender: female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Wellness visit
- No presenting symptom
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
Metformin
Metformin
Z13.5
1. Evaluation and management
2. Provider procedure codes
-
99212
92250
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range - Older adult
Patient type – outpatient
HPI – diabetic
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint – no presenting complaint
Diagnosis
2. Plan – eye exam
• Findings - normal vision and normal eye movement
3. Diagnostics – fundoscopic exam
- Results – no boat hemorrhages, no dot-blot hemorrhages, no flame
hemorrhages, no cotton wool spots
4. Therapeutic – 2000 mg PO divided in two doses.
5. Educational – managing diabetes and keeping cholesterol and blood pressure low
through diet and exercise
6. Consultation – collaborated with ophthalmologist during patient evaluation
GERIATRIC SOAP NOTES
9
H. Gingivitis 9/21done
Patient Demographics
Age: 66
1.
2.
3.
4.
Race: Latin American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem oriented
- Bleeding gum
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
Gender: Male
-
None
None
Chlorhexidine digluconate mouthwash
K05.00
1. Evaluation and management
2. Provider procedure codes
-
99202
70310
Other Questions
1. Age range - elderly adult
2. Patient type – outpatient
3. HPI – swollen gums, bleeding when brushing, tender gum, receding gums, bad
breath, active smoker
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 – puffy gums that easily bleed when brushing
Diagnoses
2. Plan– oral evaluation
• Findings – bright-red gum, receding gumline, swellen gum, and mouth sores
3. Diagnostic – dental x-ray
4. Therapeutic –using chlorhexidine digluconate 0.2% solution mouthwash
5. Education – use soft toothbrush and replace every 3 months, brush teeth twice a day,
dental floss, use mouth rinse, and do not smoke tobacco.
6. Collaboration – collaborated with dentist and periodontist during patient care
GERIATRIC SOAP NOTES
10
I. Abdominal Aortic Aneurysm Screening 9/21done
Patient Demographics
Age: 69
Race: Hispanic white
Gender: female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Preventive visit
- No presenting complaint
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
None
Z13.6
1. Evaluation and management
2. Provider procedure codes
-
99201
76700, 74176
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – older adult
Patient type – outpatient
HPI – former smoker
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit - yes
Clinical Notes
1. Chief complaint – none
Diagnoses
2. Plan – abdominal evaluation
• Findings – no palpable abdominal mass, no abdominal bruit, no flank
ecchymosis
3. Diagnostics – abdominal ultrasound and CT scan
4. Therapeutics – no medication prescribed.
5. Educational - diet and physical exercise to prevent high blood pressure and
atherosclerosis
6. Collaboration – collaborated with cardiologist during patient evaluation.
GERIATRIC SOAP NOTES
11
J. Smoking Cessation and Counselling 9/21done
Patient Demographics
Age: 70
Race: Asian
Gender: Male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Counselling
- Tobacco use
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
-
None
None
varenicline
Z71.6
1. Evaluation and management
2. Provider procedure codes
-
99202
94010
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – cigarette use
Patients primary language – Chinese
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - tobacco use
Diagnosis
2. Plan – clinical exam
• Findings – hoarseness, wheezing, stained teeth, tooth loss, hemoptysis,
dysphoria
3. Diagnostics – pulmonary function test
4. Therapeutics – varenicline 0.5 mg/day q3days followed by 0.5 mg bid q4dyas, then
1mg bid q6months
5. Educational – avoid smoking triggers, drink plenty of fluids, stay physically active,
practice stress management techniques, and attend counselling sessions
6. Consultations – collaborated with pulmonologist during patient care
GERIATRIC SOAP NOTES
12
K. Chronic constipation
Patient Demographics
Age: 68
1.
2.
3.
4.
Race: African American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 30 minute
- Problem focused
- Constipation
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
Gender: female
-
None
None
Lubiprostone
K59.09
1. Evaluation and management
2. Provider procedure codes
-
99203
36415, 45330, 45378,
91122, 74000, 74270
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI – passing fewer than 3 stools a week, hard stool, straining to have bowel
movements, feeling as though there is blockage in the rectum, pregnancy
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 - patient presents with constipation
Diagnosis
2. Plan – abdominal evaluation
• Findings – abdominal distention, palpable mass, abdominal tenderness
3. Diagnostic – blood test, sigmoidoscopy, colonoscopy, anorectal manometry, balloon
expulsion test, colonic transit study, defecography
4. Therapeutics - Lubiprostone 24 mcg PO q12 with food and water
5. Education – drink plenty fluids, pass stool frequently without ignoring urge, regular
exercise, and include plenty of fiber in daily diets
6. Collaboration – collaborated with gastroenterologist and nutritionist
GERIATRIC SOAP NOTES
13
L. Tetanus-diptheria immunization
Patient Demographics
Age: 69
1.
2.
3.
4.
Race: Pacific Islander
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Preventive medicine
- None
- Behavioral change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
Gender: female
-
None
None
Tetanus-Diphtheria vaccination
Z23
1. Evaluation and management
2. Provider procedure codes
-
99201
85027
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range –older adult
Patient type – outpatient
HPI – none
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint – no presenting complaint
Diagnoses
2. Plan – clinical evaluation
• Findings – BP- 129/88 mmHg, pulse – 90, no wheezing, no chest pain, no
abdominal tenderness, no rash, no hearing loss, no incontinence
3. Diagnostic – complete blood count
- Results - CBC results within normal range
4. Therapeutic - preventive Tetanus-Diphtheria immunization
5. Education – general healthy lifestyle including diet and exercise and importance of
immunization
6. Collaboration – collaborated with geriatrician during patient management
Running head: GERIATRIC SOAP NOTES
Geriatric Soap Notes from an FNP Perspective
Student’s Name
Institutional Affiliation
1
GERIATRIC SOAP NOTES
2
Geriatric Soap Notes from an FNP Perspective
A. Depression 9/12done
Patient Demographics
Age: 66
1.
2.
3.
4.
Race: African American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
Gender: Female
- 30 minutes
- Consultation
- Persistent feeling of sadness
- Behavioral
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- Sertraline
ICD 10 Codes
F32.9
CPT Billing
1. Evaluation and management
- 99203
2. Provider procedure codes
- 96127, 84439
Codes
Other Questions
1. Age range – elderly
2. Patient type - outpatient
3. HPI – loss of husband 7 months ago, memory difficulties, back ache, anorexia, fatigue,
loss of interest in activities, insomnia
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 – persistent feelings of sadness and loss of interest in activities after
loss of husband
Diagnoses
2. Plan – psychiatric assessment using PHQ-9
o findings – tearful, reduced concentration, cachexia, feelings of helplessness,
affect within normal limits, average eye contact, impaired sensory and motor
functions, no delusions, no hallucinations
3. Diagnostic – thyroid function test
4. Therapeutic – sertraline: initial dose 50 mg PO qd, maintenance dose 200 mg PO qd
- Psychosocial intervention – cognitive behavioral therapy and family therapy
5. Education – positive stress management practices, general improvement in social life,
and general healthy lifestyle
6. Collaborated – collaborated with geriatric psychiatrist during patient care
GERIATRIC SOAP NOTES
3
B. Type 2 Diabetes Mellitus done912
Patient Demographics
Age: 70
Race: Hispanic
Gender: Male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 15 minutes
- Clinic visit
- Numbness in the extremities
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
E11
CPT Billing
1. Evaluation and management
2. Provider procedure codes
Codes
Other Questions
1.
2.
3.
4.
5.
6.
7.
-
None
Metformin
Metformin
-
99213
83036
Age range – elderly adult
Patient type – outpatient
HPI – diabetic, fatigue, weight loss, numbness in the extremities
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint – numbness in the extremities
Diagnoses
2. Plan – clinical assessment
o findings – pigmented pretibial patches, reduced visual acuity, lung auscultation
within normal limits, normal heart sounds, no abdominal distention or tenderness,
and bilateral sensory loss in the lower and upper extremities
3. Diagnostic – Glycated hemoglobin (A1C) test
4. Therapeutic – Metformin 2000 mg per day divided in two doses
5. Education – Engage in physical activity, cease alcohol consumption, reduce fats,
sugar, and carbohydrates, eat a lot of vegetables, and drinking sufficient water every
day
6. Collaborated – collaborated with endocrinologist during patient care
GERIATRIC SOAP NOTES
4
C. Bone Mass Density Screening 9/12done
Patient Demographics
Age: 71
Race: Latino
Gender: Male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- preventive medicine
- none
- lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
Z13.820
CPT Billing
1. Evaluation and management
2. Provider procedure codes
Codes
Other Questions
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
4.
5.
6.
-
None
None
None
-
99201
77080
Age range – elderly
Patient type – outpatient
HPI – none
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
Chief complaint – no presenting chief complaint
Diagnoses
Plan – physical assessment
o findings – normal muscle tone, no fracture observed, no buffalo hump, no
kyphoscoliosis, normal back posture, no hepatomegaly, mild central obesity, no
hepatomegaly, no striae, normal thyroid tone and size
Diagnostic – bone density test (dual energy x-ray absorptiometry) of the hip and spine
Results – T-score: 0.9
Therapeutic – no medication prescribed
Education – nutritional education including intake of foods rich in calcium and regular
strength exercise to maintain health and wellbeing
Collaborated – collaborated with orthopedist during patient evaluation
GERIATRIC SOAP NOTES
D.
Rheumatoid Arthritis 9/12done
Patient Demographics
Age: 73 years
1.
2.
3.
4.
5
Race: non-Hispanic White Gender: Female
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 30 minutes
- Problem-focused visit
- Joint pain and swelling
- Behavior change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
M06.9
CPT Billing
1. Evaluation and management
2. Provider procedure codes
Codes
Other Questions
-
None
None
oral Leflunomide
99203
76881, 73120, 85027
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – tender, warm, swollen joint, joint stiffness usually worse in the morning,
fatigue, anorexia
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 – tender swollen joint
Diagnoses
2. Plan – clinical evaluation
o findings – low-grade fever (99.2 F), rheumatoid nodule over
metacarpophalangeal joints, atrophy of digital skin, rice paper skin, scleritis,
decreased breath sounds, splenomegaly, red swollen joint with tenderness on
palpation, painful on movement, and decreased range of motion
3. Diagnostic – joint Xray, ultrasound, erythrocyte sedimentation blood test
4. Therapeutic – 1*1 PO Leflunomide100mg for 3 days, AND Leflunomide 20mg q24h
maintenance dose
- Heat compresses to reduce swelling
5. Education – proper nutrition, and physical activity to address obesity
6. Collaborated – collaborated with orthopedist during patient management
GERIATRIC SOAP NOTES
6
E. Routine Hearing Test9/12done
Patient Demographics
Age: 80
1.
2.
3.
4.
Race: Pacific Islander
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Preventive test
- None
- Lifestyle change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
1.
2.
3.
4.
5.
6.
7.
Gender: Female
-
None
None
None
Z01.110
1. Evaluation and management
2. Provider procedure codes
Other Questions
-
99201
92550, 92552
Age range – elderly adult
Patient type – outpatient
HPI – none
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - routine hearing test without presenting complaint
Diagnoses
2. Plan – ear exam
o Findings – no ear impaction, no ear discharge, no swelling, flexible eardrum
3. Diagnostics – tympanometry, audiometry
4. Therapeutic – none
5. Educational: avoid exposure to excessive noise and adherence to routine checks
6. Collaboration – collaborated with audiologist during screening
GERIATRIC SOAP NOTES
7
F. Gynecomastia 9/12done
Patient Demographics
Age: 67
1.
2.
3.
4.
Race: African American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
Medications
20 minutes
Problem-focused visit
Pain in the breast region
Behavioral
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
Gender: male
-
None
None
Testosterone replacement
N62
1. Evaluation and management
2. Provider procedure codes
-
1000F, 2000F, 4000F,99202
82670, 77066, 18944,
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – increased breast size
Patients primary language – English
Chart on patient record- yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint – tenderness in the breast area
Diagnosis
2. Plan – breast exam
o Findings - enlarged breast tissue, tenderness
3. Diagnostics – blood test, estrogen-to-androgen laboratory test, mammograms
Results – no malignancy, reduced testosterone levels
4. Therapeutic – short duration testosterone replacement therapy
5. Educational – reduced alcohol consumption and cessation heroin
6. Consultation – consulted with urologist and endocrinologist
GERIATRIC SOAP NOTES
8
G. Herpes Zoster Vaccination 9/12done
Patient Demographics
Age: 65
Race: German
Gender: female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
Medications
10 minutes
Preventive visit
No presenting complain
Healthy habits
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
Shingrix vaccine
Z23
1. Evaluation and management
2. Provider procedure codes
-
99201
90750, 85027
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – none
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint – no presenting complain
Diagnosis
2. Plan – clinical assessment
o Findings – BMI 25, pulse and blood pressure within normal range, no hearing
loss, good vision, no lung crackles, no tachypenia, no heart murmurs, no
abdominal distension and tenderness, normal genito-urinary assessment results
3. Diagnostics – complete blood count
4. Therapeutic – Shingrix vaccination 1 dose
5. Educational – healthy living habits, including moderate strength workout, proper
nutrition, and stress avoidance
6. Collaboration – collaborated with geriatric physician during patient care
GERIATRIC SOAP NOTES
9
H. Parkinson’s Disease9/12done
Patient Demographics
Age: 69
Race: White
Gender: male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint
Social problems addressed.
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
15 minutes
Consultation visit
Tremor
Behavioral
-
G20
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
None
carbidopa-levodopa
-
99215
95831, 76506, 78607
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – speech changes, loss of automatic movement, rigid muscles, bradykinesia,
impaired posture, head trauma about 10 years ago
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
1.
2.
3.
4.
5.
6.
7.
Clinical Notes
Chief complaint - tremor in the limbs
Diagnosis
Plan – physical and neurologic examination
o Findings – reduced facial expression, olfactory dysfunction, jaw tremor, neck
tightness, abdominal distention, dribbling of urine, bradykinesia, shuffing gait,
and cogwheel rigidity
Diagnostic – brain ultrasound, neurology, and dopamine transporter scan
Therapeutic –carbidopa-levodopa 10mg/100 mg PO q8hr initially; levodopa increased
by 100mg/day every 2 days up to 800mg/day.
Educational - Healthy dietary habits and moderate exercise
Collaboration – collaborated with neurologist during patient care
Collaboration – collaborated with neurologist during patient evaluation and
management
GERIATRIC SOAP NOTES
10
I. Blood Pressure Testing 9/12done
Patient Demographics
Age: 66
Race: Latin American
Gender: female
Clinical Information
1.
2.
3.
4.
-
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
10 minutes
Follow-up visit
Blood pressure monitoring
Behavioral change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
Z01.30
CPT Billing
1. Evaluation and management
2. Provider procedure codes
Codes
Other Questions
1.
2.
3.
4.
5.
6.
7.
-
None
Oral hydrochlorothiazide
Oral hydrochlorothiazide
99212
81000, 93010
Age range – elderly
Patient type – outpatient
HPI – previously diagnosed with hypertension
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint – blood pressure monitoring with no presenting complaint
Diagnoses
2. Plan – cardiovascular assessment
o findings – BP of 144/94 mmHg, a pulse rate of 98 bpm, left parasternal heave,
loud P2 component of S2, diastolic murmur, panystolic murmur, ejection
midsystolic murmur, pulsative liver,
3. Diagnostic – urinalysis , electrocardiogram
4. Therapeutic – Oral hydrochlorothiazide 50mg single dose per day
5. Education – eat food low in fat and carbohydrates, increase physical activity, reduce
salt intake, maintain healthy BMI, reduce or cease alcohol consumption and cigarette
smoking, adhere to medication, and manage stress
6. Collaborated – collaborated with cardiologist during patient care
GERIATRIC SOAP NOTES
11
J. Generalized Lymphadenopathy 9/14done
Patient Demographics
Age: 69
Race: African American
Gender: Female
Clinical Information
1. Time with patient
- 10 minutes
2. Reason for visit
- Problem focused
3. Chief complaint
- Enlarged lymph nodes
4. Social problems addressed
- behavioral change
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- Lamivudine 300mg once daily
ICD 10 Codes
B23.1
CPT Billing
1. Evaluation and management
- 99213
2. Provider procedure codes
- 86701, 86360
Codes
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – persistent swelling of lymph nodes, skin 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
1.
2.
3.
4.
5.
6.
Clinical Notes
Chief complaint - enlarged lymph nodes
Diagnosis
Plan – clinical exam
o Findings – tender anterior cervical, posterior cervical, tonsillar, sub mandibular,
and supra-clavicular lymph nodes on palpation
Diagnostics – blood test, CD4 count
Results – HIV positive, CD4 count of 190
Therapeutic: Lamivudine 300mg once daily
Educational: proper nutrition, adherence to medication, ample rest, and physical
activity, safe sex practices
Collaboration – collaborated with immunologist during patient management
GERIATRIC SOAP NOTES
12
K. Prostate Cancer Screening 9/14done
Patient Demographics
Age: 68
Race: Pacific Islander
Gender: male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Preventive visit
- None
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes Z12.5
CPT Billing
Codes
-
None
Aspirin
None
1. Evaluation and management
2. Provider procedure codes
-
99201
84153
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – no presenting symptoms
Patients primary language – English
Chart on patient record – yes
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint – preventive visit with no presenting complaint
Diagnoses
2. Plan – physical and digital rectal exam
o Findings – no bladder distention, no suprapubic palpation of the bladder, no
tenderness, no asymmetrical boggy mass on digital rectal exam
3. Diagnostics – prostate-specific antigen (PSA) test
- Results – 3.7 ng/mL PSA results
4. Therapeutic – no medication prescribed
5. Educational – physical exercise and healthy feeding to incorporate food types low in
fat, and high in fiber and antioxidants
6. Collaboration – collaborated with oncologist during patient assessment
GERIATRIC SOAP NOTES
13
L. Alzheimerdone9/21done
Patient Demographics
Age: 75
Race: American Latino
Gender: female
Clinical Information
1. Time with patient
- 45 minutes
2. Reason for visit
- Consultation
3. Chief complaint
- Cognitive impairment
4. Social problems addressed
- Behavioral
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- Razadyne
3. New/refilled prescriptions
- donepezil and dextroamphetamine
ICD 10 Codes
G30.9 (F02.80)
CPT Billing
1. Evaluation and management
- 99213
2. Provider procedure codes
- 96119, 78811
Codes
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI - Memory loss that began two months ago
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 - cognitive impairment and memory loss
Diagnosis
2. Plan – mini-mental status examination
o Findings – moderate cognitive impairment, difficult concentrating, inattentive,
poor judgment
3. Diagnostics – neuropsychological testing , fluorodeoxyglucose (FDG) PET scan
4. Therapeutic - 5 mg donepezil PO QD AND dextroamphetamine 5mg PO BID
5. Educational – exercise, nutrition, adequate supervision, following up with prescription,
and safe environment
6. Collaboration - consulted with psychiatric during patient
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