Pediatric Soap Notes Patient Demographics Paper

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 Patiento Reason for visito Chief Complainto Social Problems Addressed
 Medications Section:o # OTC Medications taken regularlyo # Prescriptions currently prescribedo # 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 codeo Provider procedure codes (pap smear, destruction of lesion, sutures, etc.)
 Other Questions About This Case Category:
o Age Range
o Patient typeo HPIo Patients Primary Languageo Did you chart on the patient record?o Discussed Management with the Preceptor Handled Visit Independentlyo Preceptor Present During Visit

 Clinical Notes Category :
PLEASE follow this format
ChiefComplaint: “***”DIAGNOSIS: must havePLAN:
Diagnostics: Therapeutics:include full prescribing information safe dosing for pediatrics include weightEducation: Include (Developmental Stage guidance)
Consultation/Collaboration:

 

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