Running head: GERIATRIC SOAP NOTES
Geriatric Soap Notes from an FNP Perspective Pt7
Student’s Name
Institutional Affiliation
1
GERIATRIC SOAP NOTES
2
Geriatric Soap Notes from an FNP Perspective Pt7
A. Rosacea
Patient Demographics
Race: Hispanic white
Gender: Female
Clinical Information
Age: 71
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
-20 minutes
- problem focused
- swollen red bumps on the face
- behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
Brimonidine
Brimonidine gel topical bid
L71.9
1. Evaluation and management
2. Provider procedure codes
-
99202
95044
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – older adult
Patient type – outpatient
HPI- facial redness, eye irritation, swollen red bumps, and enlarged nose
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 - swollen bumps on the face
Diagnosis
2. Plan –skin evaluation
• Findings – warm skin with pimples on the face that resemble acne with pus
3. Diagnostics – patch test
4. Therapeutics - Brimonidine gel topical bid refill
5. Education – avoid temperature extremes, avoid spicy food, avoid cosmetics, avoid
alcohol, and sunlight
6. Consultation – collaborated with a dermatologist during patient care
GERIATRIC SOAP NOTES
3
B. Cryptococcosis
Patient Demographics
Race: African American
Gender: Female
Clinical Information
Age: 66
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Cough and chest pain
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
Lamivudine
fluconazole
B45.9
1. Evaluation and management
2. Provider procedure codes
-
99202
87076, 71010,
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI – HIV positive, cough, shortness of breath, chest pain, fever, sputum
production
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 - nonproductive cough and chest pain
Diagnosis
2. Plan – clinical exam
• Findings – no stiff neck, intact muscular strength erythematous papules and
pustules,
3. Diagnostics – chest X-ray and culture
4. Therapeutics – fluconazole 400mg PO qd for 6 months
5. Education – targeted screening and adherence to medication, avoid bird pets
6. Collaboration – collaborated with pulmonologist during patient care
GERIATRIC SOAP NOTES
4
C. Eczema
Patient Demographics
Age: 65
Race: White
Gender: Male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Problem focused
- Itchy skin
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
Propionate cream
L 20
1. Evaluation and management
2. Provider procedure codes
-
99201
95044
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – older adult
Patient type – outpatient
HPI –small-raised bumps that ooze and crust over when scratched
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 - red itchy skin
Diagnosis
2. Plan- skin assessment
• Findings- dry skin, red patches, cracked-scaly skin, small-raised bumps
3. Diagnostic – patch test
4. Therapeutic - Propionate cream
5. Education – use soap sparingly, avoid using washcloths, use unscented soap, and avoid
harsh detergents or drying soaps.
6. Consultation – consulted dermatologist during patient care
GERIATRIC SOAP NOTES
D.
5
Cryptosporidiosis
Patient Demographics
Race: Caucasian white
Gender: male
Clinical Information
Age: 76
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem-focused
- Abdominal cramps and diarrhea
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
Paromomycin, optimized ART, and
Nitazoxanide
A07.2
1. Evaluation and management
2. Provider procedure codes
-
99202
82270, 87015
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI – diarrhea, stomach cramps, fever, nausea, vomiting, weight loss, anorexia,
dehydration
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 complaint of stomach pain and watery diarrhea
Diagnosis
2. plan – clinical assessment
• findings – abdominal tenderness and distension, photophobia, congestion and
breathelessness
3. diagnostic - acid-staining test of stool sample stool test
4. Therapeutic – treatment using Paromomycin 500 mg qd 21 days plus optimized ART
and nitazoxanide for diarrhea
5. Education – hand hygiene, treatment of household water, proper cooking of food,
proper washing fruits, and limiting swimming to treated water.
6. Collaboration – consulted gastroenterologist during patient care
GERIATRIC SOAP NOTES
6
E. Lymphedema
Patient Demographics
Race: Hispanic white
Gender: Male
Clinical Information
Age: 73
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Swollen left leg
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
None
I89.0
1. Evaluation and management
2. Provider procedure codes
-
99202
78195, 93970,
73702
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – older adult
Patient type – outpatient
HPI – a feeling of heaviness, swelling of left 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 - swollen leg
Diagnosis
2. Plan – left lower limb assessment
• Findings – swelling, fibrosis, restricted range of motion
3. Diagnostics – Doppler ultrasound, lymphoscintigraphy, CT scan
4. Therapeutics – complete decongestive therapy, therapeutic exercise
5. Education – skin care, eat a diet rich in vegetables and fruits, reduce stress, exercise
daily, and get enough sleep
6. Collaboration – collaborated with hematologist, consulted physiotherapist
GERIATRIC SOAP NOTES
7
F. Psoriasis
Patient Demographics
Race: Caribbean
Gender: male
Clinical Information
Age: 70
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 5 minutes
- Problem-focused
- Dry, cracked skin that bleed
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
Betamethasone
topical betamethasone plus calcipotriene
L40.9
1. Evaluation and management
2. Provider procedure codes
-
99211
11100
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – older adult
Patient type – outpatient
HPI –itching, cracked skin that bleed
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 - patient complains of dry, cracked skin that bleed
Diagnoses
2. Plan – skin exam
• Finding – dry skin, red patches of skin covered with thick, slivery scales
3. Therapeutic – skin biopsy
4. Primary intervention – treatment using topical betamethasone plus calcipotriene q 12
hours for 1 week
5. Education – take daily baths, use moisturizers, expose skin to small amounts of
sunlight, avoid alcohol, and avoid psoriasis triggers
6. Collaboration – collaborated with dermatologist during patient care
GERIATRIC SOAP NOTES
8
G. Cutaneous Sarcoidosis
Patient Demographics
Race: African American
Gender: female
Clinical Information
Age: 65
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Skin sores
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
Prednisone
D86.0
1. Evaluation and management
2. Provider procedure codes
-
99202
11100
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – older adult
Patient type – outpatient
HPI – rash, lesions on the ears, cheeks, and nose
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 - skin lesions
Diagnosis
2. Plan– skin assessment
Findings – areas of skin that are darker in color, disfigured sore on the face, nodules
around scars, and reddish-purple bumps on the shin
3. Diagnostic – skin biopsy
4. Therapeutic – prednisone 40 mg daily
5. Education – general healthy living including diet and exercise
6. Collaboration – collaborated with dermatologist during patient care
GERIATRIC SOAP NOTES
9
H. Tetanus-Diphtheria Immunization
Patient Demographics
Age: 67
Race: African American
Gender: male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Preventive medicine
- No presenting complain
- Behavioral change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
Tetanus-Diphtheria vaccination
Z23, A35
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 – none
Diagnoses
2. Plan – clinical assessment
Findings – no breathlessness, no heart murmurs, no vision loss, no hearing loss, normal
skin tone, no abdominal tenderness and guarding
3. Diagnostic – complete blood count
4. Therapeutic - Tetanus-Diphtheria vaccine shot
5. Education – general healthy lifestyle including diet and exercise and importance of
immunization
6. Collaboration – collaborated with geriatrician during patient management
GERIATRIC SOAP NOTES
10
I. Gallstones
Patient Demographics
Age: 74
1.
2.
3.
4.
Race: Native American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem-focused evaluation
- Back pain
- Behavioral change
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
Gender: female
-
Ibuprofen
None
Ursodiol
K80.1
1. Evaluation and management
2. Provider procedure codes
-
99202
74170
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI – back pain between shoulder blades, vomiting, diarrhea, and nausea, upper
abdominal 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 - back pain between shoulder blades
Diagnosis
2. Plan – upper abdomen evaluation
Findings – distention, tenderness, rebound tenderness, palpable mass
3. Diagnostics – CT scan
4. Therapeutic – Ursodiol PO 5 mg to be taken for 2 years
5. Educational – proper nutrition including low fat diet, high fiber foods, and low
cholesterol as well as exercise to maintain a healthy BMI
6. Collaboration – collaborated with gastroenterologist during patient care
GERIATRIC SOAP NOTES
11
J. Pyelonephritis
Patient Demographics
Age: 69
1.
2.
3.
4.
Race: African American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Abdominal pain
- 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
cefazolin and cephalexin
-
99202
87088, 51798
N10
1. Evaluation and management
2. Provider procedure codes
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI - abdominal pain, hematuria, urine with bad odor, frequent urination, fever,
chills, pain when urinating
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 – abdominal pain
Diagnoses
2. Plan – abdominal assessment
Findings – suprapubic tenderness, positive sonopalpation test of the kidneys,
costovertebral angle tenderness
3. Diagnostics – urine test, bladder function evaluation
4. Therapeutic - cefazolin IV q24h followed by cephalexin PO for 10 days
5. Educational: increased fluid intake and increased micturition
6. Follow up – urinalysis every month to rule out bacteriuria that can trigger another
pyelonephritis
7. Collaboration – collaborated with nephrologist during patient care
GERIATRIC SOAP NOTES
12
K. Irritable Bowel Syndrome
Patient Demographics
Age: 66
1.
2.
3.
4.
Race: African American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem-focused evaluation
- Abdominal pain
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
2.
3.
4.
5.
6.
-
Acetaminophen
None
No drug prescribed
K58.9
1. Evaluation and management
2. Provider procedure codes
-
99202
74170, 45378, 83516
Other Questions
Age range - older adult
Patient type – outpatient
HPI – excess gas, abdominal pain, diarrhea
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 – abdominal pain
Diagnosis
Plan – abdominal assessment
• Findings - abdominal tenderness on palpation
Diagnostics – colonoscopy, CT scan, gluten intolerance test
Therapeutic – no drug prescribed
Educational – regular exercise, drink plenty of fluids, consume high fiber foods, get
enough sleep, avoid gluten
Collaboration – collaborated with gastroenterologist during patient care.
1.
2.
3.
4.
5.
6.
7.
1.
Gender: Male
GERIATRIC SOAP NOTES
13
L. Non-Ulcer Dyspepsia
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
20 minutes
Problem focused visit
Discomfort in the upper abdomen
General healthy habits
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
-
None
None
omeprazole
K30
1. Evaluation and management
2. Provider procedure codes
-
99202
36415, 83013, 43235
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – older adult
Patient type – outpatient
HPI – nausea, bloating, an early feeling of fullness when eating, belching
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 – Discomfort in the upper abdomen
Diagnosis
1. Plan – abdominal assessment
• Findings – epigastric tenderness
2. Diagnostic – blood test, H.pylori test, upper gi endoscopy
3. Therapeutic – omeprazole 20 mg PO qd in the morning for 14 days
4. Educational – eat small more frequent, avoid skipping meals, healthy living habits
including diet and exercise
5. Collaboration and referral – collaborated with gastroenterologist 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. Spinal Stenosis done
Patient Demographics
Age: 73
1.
2.
3.
4.
Race: Hispanic white
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Back pain
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
Gender: Male
-
Ibuprofen
None
Diclofenac
M48.06
1. Evaluation and management
2. Provider procedure codes
-
99202
72050, 72148
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – older adult
Patient type – outpatient
HPI – back pain mainly associated with walking
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 – back pain
Diagnoses
2. Plan – examination of the spine
• Findings – positive for hyperreflexia, abnormal gait, positive straight leg test,
weak knee and ankle reflexes positive Romberg test. pain relieved by spinal
flexion
3. Diagnostic – Back X-ray and MRI
4. Therapeutic – Diclofenac 25 mg PO qid
5. Educational – regular exercise and proper nutrition
6. Collaboration – collaborated with orthopedist during pain care.
GERIATRIC SOAP NOTES
3
B. Piriformis Syndrome done
Patient Demographics
Age: 71
1.
2.
3.
4.
Race: Hispanic white
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- buttocks pain
- 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
Ibuprofen
G57.01
1. Evaluation and management
2. Provider procedure codes
-
99202
72148
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range –older adult
Patient type – outpatient
HPI – pain and numbness in the buttocks and down 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 - buttock pain
Diagnoses
2. Plan – assessment of the back
o Findings – abnormal gait, positive straight leg test,
3. Diagnostic – MRI
4. Therapeutic – ibuprofen 200 mg PO qid
5. Education – stretching exercise and appropriate nutrition
6. Collaboration – collaborated with neurologist during patient care
GERIATRIC SOAP NOTES
C. Spinal Disc Herniation done
Patient Demographics
Age: 65
Race: African American
Gender: male
Clinical Information
1. Time with patient
- 20 minutes
2. Reason for visit
- Problem focused
3. Chief complaint
- Lower back pain
4. Social problems addressed
- Lifestyle
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- Diclofenac
ICD 10 Codes
M51.06
CPT Billing
1. Evaluation and management
- 99202
Codes
2. Provider procedure codes
- 72050, 72126, 72148
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI – lower back pain that radiates to the legs
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.
7.
4.
5.
Clinical Notes
Chief complaint - lower back pain
Diagnosis
Plan – back assessment
o Findings – positive for hyperreflexia, abnormal gait, positive straight leg test,
weak knee and ankle reflexes
Diagnostics – X-ray, CT scan, MRI
Therapeutic - Diclofenac 25 mg PO qid
Educational – proper nutrition and low intensity exercise
Collaboration – collaborated with orthopedist during patient care
4
GERIATRIC SOAP NOTES
5
D. Depression done
Patient Demographics
Age: 68
1.
2.
3.
4.
Race: American Latino
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 30 minutes
- Consultation
- Major mood change
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
F32.9
CPT Billing
Codes
Gender: female
-
None
Aripiprazole
Bupropion SR
1. Evaluation and management
2. Provider procedure codes
-
99202
85027, 84439
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI - has loss of appetite, irritability, difficulty concentrating, loss of interest in daily
activities, persistent anxiety, hopeless moods, unexplained weight gain, insomnia,
persistent sadness
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 – major changes in mood
Diagnosis
2. Plan - psychiatry evaluation
o Findings – irritable, restlessness, impair thought and concentration, slowed
movement and speech
3. Diagnostic – complete blood count, thyroid function test
4. Therapeutic – 1*2 Bupropion SR 200mg/day q 14days
5. Follow up - follow up after 2 weeks for titration
6. Educational – positive stress management practices, general improvement in social life,
and general healthy lifestyle
7. Consultation – consulted with psychiatrist during patient evaluation
GERIATRIC SOAP NOTES
6
E. Anal Fissure done
Patient Demographics
Age: 65
1.
2.
3.
4.
Race: African American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Consultation
- Anal pain during bowel movement
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
Gender: male
-
Ibuprofen
None
nitroglycerin ointment
K60.2
1. Evaluation and management
2. Provider procedure codes
-
99202
46600
Other Questions
1. Age range – older adult
2. Patient type – outpatient
3. HPI - constipation, frequent episodes of watery diarrhea, bright red spot on toilet
paper, anal 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 pain during bowel movement
Diagnosis
2. Plan – anal evaluation
o Findings – breach and laceration of the skin, exquisitely tender, anoderm with
exposed internal sphincter
3. Diagnostic – anoscopy
4. Therapeutic - 0.4% nitroglycerin ointment q 12 for 8weeks
5. Home management remedy using Sitz bath: sit in warm water for 15 minutes q12 for 4
weeks
6. Educational - consumption high fiber foods and high fluid intake
7. Consultation – consulted with gastroenterologist during patient care
GERIATRIC SOAP NOTES
7
F. Hemorrhoidsdone
Patient Demographics
Age: 66
Race: Biracial
Gender: Female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 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
None
K64.9
1. Evaluation and management
2. Provider procedure codes
Other Questions
-
99201
99201
1. Age range – Senior adult
2. Patient type – outpatient
3. HPI – pregnancy, 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
o Findings – scratch marks and skin tags in the anal verge
3. Diagnostic – digital rectal exam
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
G. Generalized Lymphadenopathy done
Patient Demographics
Age: 66
Race: Latino
Gender: Female
Clinical Information
5. Time with patient
- 10 minutes
6. Reason for visit
- Problem focused
7. Chief complaint
- Enlarged lymph nodes
8. Social problems addressed
- behavioral change
Medications
4. OTC medications taken regularly
- None
5. Prescriptions currently prescribed
- None
6. New/refilled prescriptions
- Lamivudine 300mg once daily
ICD 10 Codes
r59.9
CPT Billing
3. Evaluation and management
- 99213
Codes
4. Provider procedure codes
- 86701, 86360
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 supra-clavicular, anterior cervical, posterior cervical, sub
mandibular, and tonsillar 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
8
GERIATRIC SOAP NOTES
9
H. Prostate Cancer Screeningdone
Patient Demographics
Age: 73
Race: Hispanic
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
10
I. Routine Hearing Testdone
Patient Demographics
Age: 81
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
Metformin
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 – metformin 2000 mg refilled
5. Educational: avoid exposure to excessive noise and adherence to routine checks
6. Collaboration – collaborated with audiologist during screening
GERIATRIC SOAP NOTES
11
J. Diabetes Mellitus Type IIdone
Patient Demographics
Age: 65
Race: Hispanic
Gender: female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Clinic visit
- Increased thirst and hunger
- 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
Codes
2. Provider procedure codes
Other Questions
1.
2.
3.
4.
5.
6.
7.
-
None
None
Metformin
-
99213
83036
Age range – elderly adult
Patient type – outpatient
HPI –fatigue, weight loss, thirst and hunger
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 – increased thirst and hunger
Diagnoses
2. Plan – clinical assessment
o findings –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 500 mg per day
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
12
K. Tuberculosis done
Patient Demographics
Age: 74
1.
2.
3.
4.
Race: non-Hispanic white
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
Gender: Male
- 20 minutes
- problem-focused visit
- chest pain and coughing up phlegm
- behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
-
A15.0
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
Insulin therapy
Isoniazid, rifampicin,
pyrazinamide and ethambutol
99202
36415, 71046, 87205
1. Age range – elderly adult
2. Patient type - outpatient
3. HPI – coughing for 4 weeks, chest pain, night sweats, chills, anorexia, fatigue, fever,
unintended weight loss
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 pain and a bad cough with phlegm for 4 weeks
Diagnoses
2. Plan – pulomanry exam
o Findings – bronchial breath sounds, rhonchi, rales, and decreased breath sounds
3. Diagnostic – blood test, x-ray, sputum test
4. Therapeutic – treatment using Isoniazid 300mg, rifampicin 600mg, pyrazinamide 2g,
and ethambutol 1.6 g PO qd for 8 weeks.
5. Education – cover your mouth when coughing, sneezing, or laughing, stay in ventilated
rooms, and stay home during the first few weeks of treatment for active TB.
6. Collaborated – collaborated with pulmonologist during patient care
GERIATRIC SOAP NOTES
13
L. Onychomycoses done
Patient Demographics
Race: Hispanic white
Gender: Male
Clinical Information
Age: 75
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Problem –focused
- Brittle, discolored nails
- Hygiene
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
Terbinafine
B35.1
1. Evaluation and management
2. Provider procedure codes
-
99201
87220
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – deformed toes nails, slightly foul smell
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 – brittle discolored nails
Diagnoses
2. Plan – toe exam
o Findings - brittle, thickened, yellow-brown discoloration of the toe nails,
distorted shape, dark color,
3. Diagnostic - calcofluor white/potassium hydroxide (KOH) mount
4. Therapeutic - treatment using terbinafine 250 mg PO q24h for 12 weeks
5. Education – trim nails straight across, choose shoes made of aterials that btreathe,
discard or disinfect old shoes, wear footwear in pool areas, give up on artificial nails
and nail polish, consider a nail a salon that utilize sterilized manicure equipment
6. Collaboration – consulted dermatologist 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. Thyroid Function Screening done
Patient Demographics
Age: 69
Race: White
Gender: Female
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
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
4.
5.
6.
10 minutes
Preventive visit
No presenting complain
Lifestyle
-
Z13.29
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
None
No medication prescribed
-
99201
84436; 84443; 84479
Age range – elderly adult
Patient type – outpatient
HPI – no presenting symptom
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 symptoms
Diagnosis
Plan – clinical exam
o Findings – no goiter, no puffy face, no muscle stiffness, tenderness, and aches,
no impaired memory, normal skin consistency, no thinning of hair
Diagnostic – thyroid panel
Therapeutic – no medication prescribed
Educational – healthy living habits of proper nutrition and exercise
Collaboration – collaborated with endocrinologist during patient evaluation
GERIATRIC SOAP NOTES
3
B. Anticoagulation Management Evaluation done
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.
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.
10 minutes
Follow visit
No presenting complain
Lifestyle
-
Z79.01
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
Warfarin
Warfarin
-
99212
93793
Age range – elderly adult
Patient type – outpatient
HPI – deep vein thrombosis diagnosed three months ago
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 symptoms
Diagnosis
2. Plan – clinical exam
o Findings – no cyanotic and cold nail bed, lips, and skin, no generalized edema,
no ascites, no hepatomegaly, no jugular vein distension, no Graham-Steell
murmur
3. Diagnostic – prothrombin time and international normalized ratio
4. Therapeutic – warfarin 2 mg PO
5. Educational – healthy living habits including proper nutrition and exercise
6. Collaboration – collaborated with hematologist during patient evaluation
GERIATRIC SOAP NOTES
4
C. Brain Natriuretic Peptide Level Assessment done
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.
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.
10 minutes
Follow visit
No presenting complain
Lifestyle
-
I50.9
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
Lisinopril
Lisinopril
-
99212
83880
Age range – elderly adult
Patient type – outpatient
HPI – history of heart failure
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 symptoms
Diagnosis
2. Plan – clinical exam
o Findings – third heart sound and gallop rhythm, reduced edema of the ankle,
mild ascites, pleural effusion, rales,
3. Diagnostic – brain natriuretic peptide test
4. Therapeutic – lisinopril 40 mg PO
5. Educational – proper management of stress, weight control, reduced sodium
intake, and exercise
6. Collaboration – collaborated with cardiologist during patient evaluation
GERIATRIC SOAP NOTES
D.
5
Seborrheic Keratosis done
Patient Demographics
Age: 73 years
1.
2.
3.
4.
Race: non-Hispanic White Gender: male
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Problem focused
- Itchy skin growths
- Lifestyle
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.
-
Acetaminophen
None
hydrogen peroxide
(Eskata)
L82.1
1. Evaluation and management
2. Provider procedure codes
Other Questions
-
99201
11102
Age range – elderly adult
Patient type – outpatient
HPI – itchy skin growths appearing on the back
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 – itchy skin growths
Diagnoses
2. Plan – skin assessment
o findings – tan, oval shaped wartlike growths, slightly raised with a scaly
surface, has a characteristic pasted on look
3. Diagnostic – skin biopsy
4. Therapeutic – 40% hydrogen peroxide (Eskata)
5. Education – general healthy habits including regular exercise, geriatric immunizations,
and proper nutrition
6. Collaborated – collaborated with dermatologist during patient care
GERIATRIC SOAP NOTES
6
E. Dry Skin (Xerosis) done
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
- Problem focused
- Itchy skin
- Lifestyle
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: male
-
None
None
Moisturizers
L85.3
1. Evaluation and management
2. Provider procedure codes
Other Questions
-
99201
84436; 84443; 84479
Age range – elderly adult
Patient type – outpatient
HPI – feeling of skin tightness, especially after showering and itching
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 - itchy skin
Diagnoses
2. Plan – skin assessment
o Findings – skin that looks rough, fine cracks, slight scaling
3. Diagnostics – thyroid panel
- Results – no hypothyroidism
4. Therapeutic – moisturizers
5. Educational – limit bathing time to 10 minutes, apply moisturizers, skip drying soap,
cover as much skin as possible during windy or cold weather
6. Collaboration – collaborated with dermatologist during patient care
GERIATRIC SOAP NOTES
7
F. Senile Purpura done
Patient Demographics
Age: 87
1.
2.
3.
4.
Race: African American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Skin bruises
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing
Codes
Gender: Female
-
None
Metformin
Metformin
D69.2
1. Evaluation and management
2. Provider procedure codes
-
99202
85027, 80069, 80076,
85652
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – skin bruises
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 – skin bruises
Diagnosis
2. Plan – skin assessment
o Findings – red ecchymoses that irregularly shaped
3. Diagnostics – complete blood count, renal function test, liver function test, erythrocyte
sedimentation rate test
4. Therapeutic – Metformin 2000 mg daily divided dose
5. Educational – wear long-sleeved shirts and hats can help protect the skin from the sun,
and try to avoid bumps and bruises as much as possible
6. Consultation – consulted with dermatologist during patient care
GERIATRIC SOAP NOTES
8
G. Pruritus done
Patient Demographics
Age: 76
1.
2.
3.
4.
Race: Latino-American
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 10 minutes
- Problem focused
- Itchy skin
- 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
Calamine
L29.9
1. Evaluation and management
2. Provider procedure codes
-
99201
85027
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – itchy skin of the left arm
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 – itchy skin
Diagnosis
2. Plan – skin assessment
o Findings – red skin
3. Diagnostics – complete blood count
4. Therapeutic – apply calamine twice a day
5. Educational – wear long-sleeved shirts and hats can help protect the skin from the sun,
and try to avoid bumps and bruises as much as possible
6. Consultation – consulted with dermatologist during patient care
GERIATRIC SOAP NOTES
9
H. Tinea Cruris done
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.
- 10 minutes
- Problem focused
- Rash in groin
- Lifestyle
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.
-
B35.6
3. Evaluation and management
4. Provider procedure codes
Other Questions
None
None
clotrimazole
-
99201
87102, 87206
Age range – elderly adult
Patient type – outpatient
HPI – rash in groin area
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 - rash in the groin
Diagnosis
2. Plan – skin assessment
o Findings – papulosquamous, erythematous, annular, well-circumscribed
superficial rash with central clearing on the groin
3. Diagnostic – skin culture
4. Therapeutic – clotrimazole cream USP, 2*45mg BID for 4 weeks.
5. Educational - patient is health educated on general hygiene, avoidance of sharing
personal things like bathing towels, not wearing wet or too tight inner pants.
6. Collaboration – collaborated with dermatologist during patient care
GERIATRIC SOAP NOTES
10
I. Pinguecula done
Patient Demographics
Age: 68
Race: Latina
Gender: Female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint
Social problems addressed.
- 10 minute
- Problem-focused visit
- Eye irritation
- Behavioral
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.
-
None
None
Eye drop (oculist)
H11.151
1. Evaluation and management
2. Provider procedure codes
Other Questions
- 99201
- 92004
Age range – elderly adult
Patient type – outpatient
HPI – particle sensation and scratching in the right eye
Patients primary language – English
Chart on patient record – none
Discussed management with the preceptor handled visit independently – yes
Preceptor present during visit – yes
Clinical Notes
1. Chief complaint - right eye irritation
Diagnosis
2. Plan – eye evaluation
o Findings – yellow mass in on the conjunctiva
3. Diagnostic – slit lamp exam
4. Therapeutic - 0.05% Azelastine (oculast), 1 drop tid for 5 days.
5. Educational - use anti UV sunglasses and cape when going out to the sun
6. Consultation – consulted with ophthalmologist during patient evaluation
GERIATRIC SOAP NOTES
11
J. Atrophic Rhinitis done
Patient Demographics
Age: 75
1.
2.
3.
4.
Race: White
Gender: male
Clinical Information
Time with patient
- 10 minutes
Reason for visit
- Problem-focused visit
Chief complaint
- Runny nose and itchy throat
Social problems addressed
- Behavioral
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- Fluticasone propionate
ICD 10 Codes
J31.0
CPT Billing
1. Evaluation and management
- 99201
2. Provider procedure codes
- 95180
Codes
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI - Stuffy runny nose, sneezing, and itchy throat that began two 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
1.
2.
3.
4.
5.
6.
Clinical Notes
Chief complaint – stuffy-runny nose and itchy throat
Diagnosis
Plan – clinical evaluation
Findings - periorbital edema, nasal congestion, rhinorrhea, mucus discharge
Diagnostics – skin and blood test for possible allergy
Therapeutic - Fluticasone propionate 50 ug, two sprays/ nose / day for 4 days
Educational – avoid stress and irritants such as smog, exhaust fumes
Consultation - consulted with immunologist during patient evaluation
GERIATRIC SOAP NOTES
12
K. Urinary Tract Infection done
Patient Demographics
Age: 66
Race: Mexican
Gender: female
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed
- 30 minutes
- problem focused
- pelvic pain
- behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
N39.0
CPT Billing Codes
1. Evaluation and management
2. Provider procedure codes
Other Questions
-
None
None
Ciprofloxacin
-
99203
81001
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – strong persistent urge to urinate, strong smelling urine, pelvic discomfort,
passing frequent, amounts of urine, bright pink colored urine
4. Patients primary language – Spanish
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 – pelvic pain and burning sensation during micturition
Diagnoses
2. Plan – pelvic exam
o Findings – discomfort in response to pressure on the area above pelvic bone,
growths, urethra discharge
3. Diagnostic – urinalysis and culture
4. Therapeutic – ciprofloxacin 500 mg bid 14 days
5. Education – improved hygiene, consume a lot of fluids, and safe sex practices
6. Collaborated – collaborated with urologist during patient care
GERIATRIC SOAP NOTES
13
L. Vitamin B12 Level Screeningdone
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.
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.
1.
2.
3.
4.
5.
6.
10 minutes
Preventive visit
No presenting complain
Lifestyle
-
Z13.21
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
None
No medication prescribed
-
99201
83921, 78270
Age range – elderly adult
Patient type – outpatient
HPI – bowel surgery three years ago
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 symptoms
Diagnosis
Plan – clinical exam
o Findings – no goiter, no puffy face, no muscle stiffness, tenderness, and aches,
no impaired memory, normal skin consistency, no thinning of hair
Diagnostic – methylmalonic acid test, schilling test
Therapeutic – no medication prescribed
Educational – healthy living habits of proper nutrition and exercise
Collaboration – collaborated with internal medicine specialist during patient evaluation
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 done
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 done
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 done
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 Billing Codes
1. Evaluation and management
2. Provider procedure codes
Other Questions
1.
2.
3.
4.
5.
6.
7.
-
None
None
Iron supplements
-
99201
85027 , 82728
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 – none
Diagnoses
2. Plan – clinical evaluation
o Findings – normal skin color, no brittle nails, no tongue inflammation, no cold
feet and hands
3. Diagnostic – complete blood count, ferritin panel
4. Therapeutic – iron supplements
5. Education – consume diets rich in iron including peas,, dark green leafy vegetables,
beans, seafood
6. Collaborated – collaborated with nutrition expert
GERIATRIC SOAP NOTES
D.
5
Focal Epilepsy done
Patient Demographics
Age: 73 years
1.
2.
3.
4.
Race: non-Hispanic White Gender: Female
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Seizures
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
G40.209
-
None
None
Lamotrigine
CPT Billing
Codes
-
99202
95819, 70460, 78815
1. Evaluation and management
2. Provider procedure codes
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – seizures, involuntary jerking of arms, flashing lights, temporary confusion,
anxiety, falls
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 – seizures
Diagnoses
2. Plan – Neurological exam
o findings – normal neurological function including normal olfactory, optic, extra
ocular movements, normal reflexes (2+), and absence of palsy
3. Diagnostic – positron emission tomography, electroencephalogram, brain CT-scan
4. Therapeutic – Lamotrigine initial dose 25 mg/ daily, maximum dose: 225 mg/daily
5. Education – get enough sleep, safe regular exercise, wear medical alert bracelet, and
adherences to medication prescription
6. Collaborated – collaborated with neurologist during patient care
GERIATRIC SOAP NOTES
6
E. Cholesterol Screening done
Patient Demographics
Age: 69
Race: White
Gender: female
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
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
4.
5.
6.
10 minutes
Preventive visit
No presenting complain
Lifestyle
-
Z13.220
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
None
Atorvastatin
-
99201
80061
Age range – elderly adult
Patient type – outpatient
HPI – no presenting symptom
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 symptoms
Diagnosis
Plan – clinical exam
o Findings – no xanthoma, no xanthelasma palpabrum, normal dorsalis, posterior
tibial, and femoral pulses, no femoral bruits, no signs of transient ischemic
attacks
Diagnostic – lipid panel
Therapeutic – atorvastatin 10 mg PO qd initially and 80 mg PO qd maintenance dose
Educational – healthy living habits of proper nutrition and exercise
Collaboration – collaborated with lipid specialist during patient evaluation
GERIATRIC SOAP NOTES
7
F. Thyroid Function Screening done
Patient Demographics
Age: 69
Race: White
Gender: female
Clinical Information
5.
6.
7.
8.
Time with patient
Reason for visit
Chief Complaint
Social problems addressed.
Medications
4. OTC medications taken regularly
5. Prescriptions currently prescribed
6. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
10 minutes
Preventive visit
No presenting complain
Lifestyle
-
Z13.29
3. Evaluation and management
4. Provider procedure codes
None
None
No medication prescribed
-
99201
84436; 84443; 84479,
76536
Other Questions
8. Age range – elderly adult
9. Patient type – outpatient
10. HPI – no presenting symptom
11. Patients primary language – English
12. Chart on patient record – yes
13. Discussed management with the preceptor handled visit independently – yes
14. Preceptor present during visit – yes
Clinical Notes
7. Chief complaint - no presenting symptoms
Diagnosis
8. Plan – thyroid assessment
o Findings – no heart palpitation, no anxiety, normal goiter, no tremors, no
tenderness of lymph nodes
9. Diagnostic – thyroid panel serum test, thyroid ultrasound
- Results - Normal thyroid function
10. Therapeutic – no medication prescribed
11. Educational – healthy living habits of proper nutrition and exercise
12. Collaboration – collaborated with endocrinologist during patient evaluation
GERIATRIC SOAP NOTES
8
G. Chronic Bronchitis done
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
20 minutes
Problem focused
Cough
Behavioral
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
ipratropium
J41.0
1. Evaluation and management
2. Provider procedure codes
-
99203
94760, 94060, 71010
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – chest discomfort, mild fever, cough, sputum production, breathlessness,
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 – productive cough
Diagnosis
2. Plan – lung exam
13. Findings – distress and hoover’s sign upon inspection, wheezing, coarse crackles and
rhonchi upon auscultation
3. Diagnostics – pulse oximetry, spirometry, chest X-ray
4. Therapeutic – ipratropium 2 puffs every 6 hours
5. Educational – hand-hygiene, and general healthy lifestyle
6. Collaboration – collaborated with pulmonologist during patient care
GERIATRIC SOAP NOTES
9
H. Kidney Function Screening done
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
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
4.
5.
6.
10 minutes
Wellness visit
No presenting complain
Lifestyle
-
Z13.89
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
Oral hydrochlorothiazide
Oral hydrochlorothiazide
-
99201
80069
Age range – elderly adult
Patient type – outpatient
HPI – 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
Chief complaint - no presenting symptoms
Diagnosis
Plan – clinical exam
o Findings – no swelling of the feet, ankles, and legs
Diagnostic – serum test
- Results - Normal kidney function
Therapeutic – oral hydrochlorothiazide
Educational – healthy living habits of proper nutrition and exercise
Collaboration – collaborated with nephrologist during patient evaluation
GERIATRIC SOAP NOTES
10
I. Uncomplicated Pneumonia done
Patient Demographics
Age: 66
1.
2.
3.
4.
Race: Latin American
Gender: female
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
Medications
20 minutes
Problem focused
Mild cough
Behavioral
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
J18.9
CPT Billing
1. Evaluation and management
2. Provider procedure codes
Codes
Other Questions
1.
2.
3.
4.
5.
6.
7.
-
None
None
Azithromycin
-
99202
71035, 94760, 87880
Age range – elderly
Patient type – outpatient
HPI – HIV, mild fever, breathlessness, and mild cough
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 – mild cough
Diagnoses
2. Plan – pulmonary exam
o findings – increased tactile fremitus on palpation, bronchial breath sounds,
rhonchi, crackle, vocal fremitus, and reduced breath sounds on auscultation,
and dullness on percussion
3. Diagnostic – strep test, pulse oximetry, chest X-ray
4. Therapeutic – Azithromycin 500 mg PO one dose, then 250 mg PO daily for 4 d
5. Education – Geriatric immunization, good hand-hygiene
6. Collaborated – collaborated with pulmonologist during patient care
GERIATRIC SOAP NOTES
J. Chronic Fatigue Syndrome done
Patient Demographics
Age: 65
Race: African American
Gender: Female
Clinical Information
1. Time with patient
- 20 minutes
2. Reason for visit
- Problem focused
3. Chief complaint
- Fatigue
4. Social problems addressed
- Lifestyle
Medications
1. OTC medications taken regularly
- Acetaminophen
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- No medication prescribed
ICD 10 Codes
R53.82
CPT Billing
1. Evaluation and management
- 99202
2. Provider procedure codes
- 80091, 85027, 83036
Codes
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – sore throat, headache, fatigue, unrefreshing sleep, extreme exhaustion,
unexplained joint 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
1.
2.
3.
4.
5.
6.
Clinical Notes
Chief complaint - fatigue and extreme exhaustion
Diagnosis
Plan – clinical exam
o Findings – tender axillary lymph nodes, impaired cognitive dysfunction
Diagnostics – complete blood count, thyroid function test, hemoglobin A1C test
Therapeutic – cognitive training and graded exercise therapy
Educational – healthy lifestyle of healthy nutrition and exercise
Collaboration – collaborated orthopedist during patient care
11
GERIATRIC SOAP NOTES
12
K. Diabetic Neuropathy (Foot Exam)done
Patient Demographics
Age: 73
Race: Pacific Islander
Gender: male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Numbness in the legs
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes E11.40
CPT Billing
Codes
-
None
Insulin
amitriptyline
1. Evaluation and management
2. Provider procedure codes
-
99202
95887
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – numbness, tingling sensation, cramps
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 feet
Diagnoses
2. Plan – periphery assessment
o Findings – loss of reflexes, muscle weakness, sensitivity to touch, no ulcer
3. Diagnostics – electromyopraphy
4. Therapeutic – amitriptyline 10 mg per day
- Tight glycemic control
5. Educational – make healthy food choices and be active everyday
6. Collaboration – collaborated with neurologist during patient care
GERIATRIC SOAP NOTES
L. Osteoarthritis done
Patient Demographics
Age: 75
Race: American Latino
Gender: female
Clinical Information
1. Time with patient
- 20 minutes
2. Reason for visit
- Problem focused
3. Chief complaint
- Pain in the knee
4. Social problems addressed
- Lifestyle
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- Acetaminophen
ICD 10 Codes
M17.11
CPT Billing
1. Evaluation and management
- 99202
2. Provider procedure codes
- 73560, 89051
Codes
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – pain in the right knee during and after movement
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 right knee
Diagnosis
2. Plan – knee assessment
o Findings – stiffness, tenderness, swelling, loss of flexibility
3. Diagnostics – joint X-ray, joint fluid analysis
4. Therapeutic – acetaminophen 650 mg qid
5. Educational – undertake low-impact exercise and observe proper nutrition to control
body weight
6. Collaboration - consulted with orthopedist during patient care
13
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 done
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 done
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 done
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 Billing Codes
1. Evaluation and management
2. Provider procedure codes
Other Questions
1.
2.
3.
4.
5.
6.
7.
-
None
None
Iron supplements
-
99201
85027 , 82728
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 – none
Diagnoses
2. Plan – clinical evaluation
o Findings – normal skin color, no brittle nails, no tongue inflammation, no cold
feet and hands
3. Diagnostic – complete blood count, ferritin panel
4. Therapeutic – iron supplements
5. Education – consume diets rich in iron including peas,, dark green leafy vegetables,
beans, seafood
6. Collaborated – collaborated with nutrition expert
GERIATRIC SOAP NOTES
D.
5
Focal Epilepsy done
Patient Demographics
Age: 73 years
1.
2.
3.
4.
Race: non-Hispanic White Gender: Female
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Seizures
- Behavioral
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
G40.209
-
None
None
Lamotrigine
CPT Billing
Codes
-
99202
95819, 70460, 78815
1. Evaluation and management
2. Provider procedure codes
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – seizures, involuntary jerking of arms, flashing lights, temporary confusion,
anxiety, falls
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 – seizures
Diagnoses
2. Plan – Neurological exam
o findings – normal neurological function including normal olfactory, optic, extra
ocular movements, normal reflexes (2+), and absence of palsy
3. Diagnostic – positron emission tomography, electroencephalogram, brain CT-scan
4. Therapeutic – Lamotrigine initial dose 25 mg/ daily, maximum dose: 225 mg/daily
5. Education – get enough sleep, safe regular exercise, wear medical alert bracelet, and
adherences to medication prescription
6. Collaborated – collaborated with neurologist during patient care
GERIATRIC SOAP NOTES
6
E. Cholesterol Screening done
Patient Demographics
Age: 69
Race: White
Gender: female
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
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
4.
5.
6.
10 minutes
Preventive visit
No presenting complain
Lifestyle
-
Z13.220
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
None
Atorvastatin
-
99201
80061
Age range – elderly adult
Patient type – outpatient
HPI – no presenting symptom
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 symptoms
Diagnosis
Plan – clinical exam
o Findings – no xanthoma, no xanthelasma palpabrum, normal dorsalis, posterior
tibial, and femoral pulses, no femoral bruits, no signs of transient ischemic
attacks
Diagnostic – lipid panel
Therapeutic – atorvastatin 10 mg PO qd initially and 80 mg PO qd maintenance dose
Educational – healthy living habits of proper nutrition and exercise
Collaboration – collaborated with lipid specialist during patient evaluation
GERIATRIC SOAP NOTES
7
F. Thyroid Function Screening done
Patient Demographics
Age: 69
Race: White
Gender: female
Clinical Information
5.
6.
7.
8.
Time with patient
Reason for visit
Chief Complaint
Social problems addressed.
Medications
4. OTC medications taken regularly
5. Prescriptions currently prescribed
6. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
10 minutes
Preventive visit
No presenting complain
Lifestyle
-
Z13.29
3. Evaluation and management
4. Provider procedure codes
None
None
No medication prescribed
-
99201
84436; 84443; 84479,
76536
Other Questions
8. Age range – elderly adult
9. Patient type – outpatient
10. HPI – no presenting symptom
11. Patients primary language – English
12. Chart on patient record – yes
13. Discussed management with the preceptor handled visit independently – yes
14. Preceptor present during visit – yes
Clinical Notes
7. Chief complaint - no presenting symptoms
Diagnosis
8. Plan – thyroid assessment
o Findings – no heart palpitation, no anxiety, normal goiter, no tremors, no
tenderness of lymph nodes
9. Diagnostic – thyroid panel serum test, thyroid ultrasound
- Results - Normal thyroid function
10. Therapeutic – no medication prescribed
11. Educational – healthy living habits of proper nutrition and exercise
12. Collaboration – collaborated with endocrinologist during patient evaluation
GERIATRIC SOAP NOTES
8
G. Chronic Bronchitis done
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
20 minutes
Problem focused
Cough
Behavioral
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
CPT Billing Codes
-
None
None
ipratropium
J41.0
1. Evaluation and management
2. Provider procedure codes
-
99203
94760, 94060, 71010
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – chest discomfort, mild fever, cough, sputum production, breathlessness,
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 – productive cough
Diagnosis
2. Plan – lung exam
13. Findings – distress and hoover’s sign upon inspection, wheezing, coarse crackles and
rhonchi upon auscultation
3. Diagnostics – pulse oximetry, spirometry, chest X-ray
4. Therapeutic – ipratropium 2 puffs every 6 hours
5. Educational – hand-hygiene, and general healthy lifestyle
6. Collaboration – collaborated with pulmonologist during patient care
GERIATRIC SOAP NOTES
9
H. Kidney Function Screening done
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
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
4.
5.
6.
10 minutes
Wellness visit
No presenting complain
Lifestyle
-
Z13.89
1. Evaluation and management
2. Provider procedure codes
Other Questions
None
Oral hydrochlorothiazide
Oral hydrochlorothiazide
-
99201
80069
Age range – elderly adult
Patient type – outpatient
HPI – 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
Chief complaint - no presenting symptoms
Diagnosis
Plan – clinical exam
o Findings – no swelling of the feet, ankles, and legs
Diagnostic – serum test
- Results - Normal kidney function
Therapeutic – oral hydrochlorothiazide
Educational – healthy living habits of proper nutrition and exercise
Collaboration – collaborated with nephrologist during patient evaluation
GERIATRIC SOAP NOTES
10
I. Uncomplicated Pneumonia done
Patient Demographics
Age: 66
1.
2.
3.
4.
Race: Latin American
Gender: female
Clinical Information
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
Medications
20 minutes
Problem focused
Mild cough
Behavioral
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
J18.9
CPT Billing
1. Evaluation and management
2. Provider procedure codes
Codes
Other Questions
1.
2.
3.
4.
5.
6.
7.
-
None
None
Azithromycin
-
99202
71035, 94760, 87880
Age range – elderly
Patient type – outpatient
HPI – HIV, mild fever, breathlessness, and mild cough
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 – mild cough
Diagnoses
2. Plan – pulmonary exam
o findings – increased tactile fremitus on palpation, bronchial breath sounds,
rhonchi, crackle, vocal fremitus, and reduced breath sounds on auscultation,
and dullness on percussion
3. Diagnostic – strep test, pulse oximetry, chest X-ray
4. Therapeutic – Azithromycin 500 mg PO one dose, then 250 mg PO daily for 4 d
5. Education – Geriatric immunization, good hand-hygiene
6. Collaborated – collaborated with pulmonologist during patient care
GERIATRIC SOAP NOTES
J. Chronic Fatigue Syndrome done
Patient Demographics
Age: 65
Race: African American
Gender: Female
Clinical Information
1. Time with patient
- 20 minutes
2. Reason for visit
- Problem focused
3. Chief complaint
- Fatigue
4. Social problems addressed
- Lifestyle
Medications
1. OTC medications taken regularly
- Acetaminophen
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- No medication prescribed
ICD 10 Codes
R53.82
CPT Billing
1. Evaluation and management
- 99202
2. Provider procedure codes
- 80091, 85027, 83036
Codes
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – sore throat, headache, fatigue, unrefreshing sleep, extreme exhaustion,
unexplained joint 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
1.
2.
3.
4.
5.
6.
Clinical Notes
Chief complaint - fatigue and extreme exhaustion
Diagnosis
Plan – clinical exam
o Findings – tender axillary lymph nodes, impaired cognitive dysfunction
Diagnostics – complete blood count, thyroid function test, hemoglobin A1C test
Therapeutic – cognitive training and graded exercise therapy
Educational – healthy lifestyle of healthy nutrition and exercise
Collaboration – collaborated orthopedist during patient care
11
GERIATRIC SOAP NOTES
12
K. Diabetic Neuropathy (Foot Exam)done
Patient Demographics
Age: 73
Race: Pacific Islander
Gender: male
Clinical Information
1.
2.
3.
4.
Time with patient
Reason for visit
Chief Complaint.
Social problems addressed.
- 20 minutes
- Problem focused
- Numbness in the legs
- Lifestyle
Medications
1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes E11.40
CPT Billing
Codes
-
None
Insulin
amitriptyline
1. Evaluation and management
2. Provider procedure codes
-
99202
95887
Other Questions
1.
2.
3.
4.
5.
6.
7.
Age range – elderly adult
Patient type – outpatient
HPI – numbness, tingling sensation, cramps
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 feet
Diagnoses
2. Plan – periphery assessment
o Findings – loss of reflexes, muscle weakness, sensitivity to touch, no ulcer
3. Diagnostics – electromyopraphy
4. Therapeutic – amitriptyline 10 mg per day
- Tight glycemic control
5. Educational – make healthy food choices and be active everyday
6. Collaboration – collaborated with neurologist during patient care
GERIATRIC SOAP NOTES
L. Osteoarthritis done
Patient Demographics
Age: 75
Race: American Latino
Gender: female
Clinical Information
1. Time with patient
- 20 minutes
2. Reason for visit
- Problem focused
3. Chief complaint
- Pain in the knee
4. Social problems addressed
- Lifestyle
Medications
1. OTC medications taken regularly
- None
2. Prescriptions currently prescribed
- None
3. New/refilled prescriptions
- Acetaminophen
ICD 10 Codes
M17.11
CPT Billing
1. Evaluation and management
- 99202
2. Provider procedure codes
- 73560, 89051
Codes
Other Questions
1. Age range – elderly adult
2. Patient type – outpatient
3. HPI – pain in the right knee during and after movement
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 right knee
Diagnosis
2. Plan – knee assessment
o Findings – stiffness, tenderness, swelling, loss of flexibility
3. Diagnostics – joint X-ray, joint fluid analysis
4. Therapeutic – acetaminophen 650 mg qid
5. Educational – undertake low-impact exercise and observe proper nutrition to control
body weight
6. Collaboration - consulted with orthopedist during patient care
13
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