Herzing WK3 Chronic Obstructive Pulmonary Disease Geriatric Soap Notes

User Generated

ZCP2019

Science

Description

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
  •  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

Unformatted Attachment Preview

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
Purchase answer to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Explanation & Answer

Attached.

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. Alcohol Use Disorder
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

- 10 minutes
- Problem focused
- Alcoholism
- Behavioral
Medications

1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- disulfiram
ICD 10 Codes
F10.99
CPT Billing
1. Evaluation and management
- 99202
2. Provider procedure codes
- 80076
Codes
Other Questions
1. Age range – elderly
2. Patient type - outpatient
3. HPI – alcohol dependency
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 – alcohol dependency
Diagnoses
2. Plan – clinical assessment
o findings – no hepatomegaly, no pancreatitis, no abnormal heart sounds,
nystagmus
3. Diagnostic – liver function test
4. Therapeutic – disulfiram 500 mg PO qd initially for 1-2 weeks, 250 mg PO qd
maintenance dose
5. Education – engage in activities that do not involve alcohol, consider your social
situations, and develop healthy habits including physical exercise
6. Collaborated – collaborated with hepatologist during patient care

GERIATRIC SOAP NOTES

3

B. Cataracts
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.

- 10 minutes
- Problem focused
- Blurred vision
- Behavioral
Medications

1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
H25.9
CPT Billing
1. Evaluation and management
2. Provider procedure codes
Codes
Other Questions

-

None
None
No medication prescribed

-

99201
99000, 92015

1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – double vision in a single eye, halos around light, yellowing of colors, difficulty
with vision at night, dim vision
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 – blurred vision
Diagnoses
2. Plan – eye exam
o findings – clouding and sensitivity to light
3.
4.
5.
6.

Diagnostic – slit-lamp exam, dilated fundus examination
Therapeutic – correctional glasses
Education – regular eye examination, safety measures, and regular exercise
Collaborated – collaborated with ophthalmologist during patient care

GERIATRIC SOAP NOTES

4

C. Anemia Screening
Patient Demographics
Age: 70

Race: Caucasian

Gender: female
Clinical Information

1.
2.
3.
4.

Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.

- 10 minutes
- wellness visit
- none
- nutritional
Medications

1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
Z13.0
CPT Bil...


Anonymous
Great! 10/10 would recommend using Studypool to help you study.

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4

Related Tags