Create 50 Soap notes FNP new grad perspective

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Create 50 Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new grad perspective. Include a variety of acute, chronic, and wellness disorders.

Documentation Requirements

Must Include

  • Patient Demographics Section:o
  • Age
  • Race
  • Gender
  •  Clinical Information Section:o
  • 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 Preceptoro Handled Visit Independently
    o Preceptor Present During Visit

 Clinical Notes Category :
o Chief Complaint patient presents with
o Primary diagnosis you determined after your comprehensive evaluation

o Primary interventions you planned relative to the primary diagnosis you

determined [e.g. diagnostics, therapeutics, educational, consultation/collaboration, etc.]