Create 12 Geriatric ONLY Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new perspective in a clinic setting. Include a variety of preventive visits, chronic, and wellness disorders annual exam pertaining only to this population.Include developmental appropriate stages. Every soap note needs a diagnosis and therapeutic section must have medications and full prescribing instructions specifically for the geriatric population. .Include low to medium complexity in ICD code.

Documentation Requirements

Must Include

• Patient Demographics Section:
• Age
• Race
• Gender
•  Clinical Information Section:
• Time with Patient
• o Reason for visit
• o Chief Complaint
• o Social Problems Addressed
•  Medications Section:
• o # OTC Medications taken regularly
• o # Prescriptions currently prescribed
• o # New/Refilled Prescriptions This Visit
•  ICD 10 Codes Category:
• o Include for each diagnosis addressed at the visit
•  CPT Billing Codes Category:
• o Include Evaluation and management code
• o Provider procedure codes (pap smear, destruction of lesion, sutures, etc.)
•  Other Questions About This Case Category:
• o Age Range
• o Patient type
• o HPI
• o Patients Primary Language
• o Did you chart on the patient record?
• o Discussed Management with the Preceptor Handled Visit Independently
• o Preceptor Present During Visit

 Clinical Notes Category :

PLEASE follow this format

ChiefComplaint: “***”

DIAGNOSIS: must have

PLAN:

Diagnostics:

Therapeutics:include full prescribing information safe dosing

Education: Include (Developmental Stage guidance)

Consultation/Collaboration:

make sure the cpt /icd10 codes match the diagnosis

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