50 soap notes for adult health
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Create 50 Adult Health Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new grad perspective. Include a variety of preventive visits,acute, chronic, and wellness disorders.
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 Preceptoro Handled Visit Independently
o Preceptor Present During Visit
Clinical Notes Category :
PLEASE follow this format
ChiefComplaint: “***”
DIAGNOSIS:
PLAN:
Diagnostics:
Therapeutics:
Education:
Consultation/Collaboration:
6 days ago