Pediatric Soap Notes Diagnosis
Create 10 PEDIATRIC ONLY (birth to 18 years old) 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 annualexam 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.
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
Education: Include (Developmental Stage guidance)
Consultation/Collaboration:
“0.
Discount Code: 0
: +1 0 0-0
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