Avoid repeating diagnosis

Help me study for my Health & Medical class. I’m stuck and don’t understand.

 

Create 10 PEDIATRIC ONLY (birth to 18 years old) Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new perspective. Include a variety of preventive visits,acute, 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 pediatric population. Include the patient’s weight.

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 for pediatrics include weight
Education: Include (Developmental Stage guidance)

Consultation/Collaboration: