Herzing FNP New Perspective in A Clinic Setting Geriatric Soap Notes HW

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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 codeshare updated and match the diagnosis

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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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Explanation & Answer

Attached.

Geriatric Soap Notes from an FNP Perspective
I.
II.

Dyspareunia
Heartburn

III.

Clinical breast exam

IV.

Vulvodynia

V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.

Pyelonephritis
Helicobacter pylori infection
Bacterial vaginosis
Cystocele
Cervical cancer screening
Belly bloat
Breast cancer screening
Diabetes testing

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. Dyspareunia
Patient Demographics
Age: 76

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
Sexual discomfort
Lifestyle

1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
N94.1
CPT Billing
1. Evaluation and management
2. Provider procedure codes
Codes
Other Questions
1.
2.
3.
4.
5.
6.
7.

-

None
None
lubricant

99201
76830

Age range – elderly
Patient type – outpatient
HPI – pain during sexual penetration
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 – sexual discomfort
Diagnoses
2. Plan – pelvic exam
o findings – no signs of anatomical problems, no swelling, no mass, normal
shiny external genitalia, no abnormal discharge, no unusual odor
3. Diagnostic – pelvic ultrasound
4. Therapeutic – lubricant for application before penetration
5. Education – change positions to achieve comfort, communicate with partner, use
lubricants
6. Collaborated – collaborated with gynecologist during patient care
B. Heartburn

GERIATRIC SOAP NOTES

3
Patient Demographics

Age: 66

1.
2.
3.
4.

Race: Latin American
Gender: male
Clinical Information

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

Medications

20 minutes
Problem focused
heartburn
Lifestyle

1. OTC medications taken regularly
2. Prescriptions currently prescribed
3. New/refilled prescriptions
ICD 10 Codes
R12
CPT Billing
1. Evaluation and management
2. Provider procedure codes
Codes
Other Questions
1.
2.
3.
4.
5.
6.
7.

-

-

None
None

99202
43235, 91010

Age range – elderly
Patient type – outpatient
HPI – burning sensation in the chest, bitter taste
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 – burning sensation in the chest
Diagnoses
2. Plan – upper GIT assessment
o findings – no epigastric tenderness, no dental erosion, no laryngitis, no
hoarseness
3. Diagnostic – esophagus endoscopy, esophageal motility testing
4. Therapeutic – Tums chewy delights 1177 mg at onset of heartburn
5. Education – avoid too spicy foods, proper nutrition and frequent exercise to control
body weight
6. Collaborated – collaborated with gastroenterologist during patient care

GERIATRIC SOAP NOTES

4

C. Clinical Breast Exam
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

10 minutes
Wellnes...


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