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:
Expert Solution Preview
Introduction:
The following are 10 pediatric SOAP notes that I have designed for medical college students. These SOAP notes are intended to provide a variety of preventive visits, acute, chronic, and wellness disorders. Every SOAP note included in this assignment includes a diagnosis and therapeutic section with medications and full prescribing instructions specifically for the pediatric population. Each note adheres to the outlined documentation requirements provided.
Answer:
SOAP note 1:
Patient Demographics Section:
Age: 18 months
Race: African American
Gender: Male
Clinical Information Section:
Time with Patient: 45 minutes
Reason for visit: Fever
Chief Complaint: “My baby has had a fever for past 2 days.”
Medications Section:
#OTC Medications taken regularly: none
#Prescriptions currently prescribed: none
#New/Refilled Prescriptions This Visit: Acetaminophen
ICD 10 Codes Category:
R50.9 Fever, unspecified
CPT Billing Codes Category:
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a focused history; a focused examination; medical decision making of low complexity.
Other Questions About This Case Category:
Age Range: 0-18 years
Patient type: New patient
HPI: Fever 38.5°C started 2 days ago, symptomatic treatment given by mother
Patients Primary Language: English
Did you chart on the patient record? Yes
Discussed Management with the Preceptor: Yes
Handled Visit Independently: No
Preceptor Present During Visit: Yes
Clinical Notes Category:
Chief Complaint: “My baby has had a fever for past 2 days.”
DIAGNOSIS: Viral Illness
PLAN:
Diagnostics: none
Therapeutics: Acetaminophen 15mg/kg/dose every 4 hours as needed for fever, do not exceed 5 doses in 24hrs
Weight: 12.6 kg
Education: Symptomatic treatment, encourage fluid intake, follow up if fever persists after 5 days
Consultation/Collaboration: None
