Geriatric Soap Notes from an FNP Perspective SampleDepression 9/12donePatient DemographicsAge: 66Rac

---

Geriatric Soap Notes from an FNP Perspective Sample

1. Depression 9/12done

Patient Demographics

Age: 66Race:  African AmericanGender:  FemaleClinical Information 1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–           30 minutes

–          Consultation

–          Persistent feeling of sadness

–          Behavioral

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–           None

–          None

–          Sertraline

ICD 10 CodesF32.9CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

–          99203

–          96127, 84439

Other Questions 1.      Age range – elderly

2.      Patient type –  outpatient

3.      HPI – loss of husband 7 months ago, memory difficulties, back ache, anorexia, fatigue, loss of interest in activities, insomnia

4.      Patients primary language – English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

Clinical Notes1.      Chief complaint – persistent feelings of sadness and loss of interest in activities after loss of husband

Diagnoses

2.      Plan – psychiatric assessment using PHQ-9

o   findings –  tearful, reduced concentration, cachexia, feelings of helplessness, affect within normal limits, average eye contact, impaired sensory and motor functions, no delusions, no hallucinations

3.      Diagnostic –  thyroid function test

4.      Therapeutic –  sertraline: initial dose 50 mg PO qd, maintenance dose 200 mg PO qd

–          Psychosocial intervention – cognitive behavioral therapy and family therapy

5.      Education –  positive stress management practices, general improvement in social life, and general healthy lifestyle

6.      Collaborated – collaborated with geriatric psychiatrist during patient care

Type 2 Diabetes Mellitus done912

Patient Demographics

 

Age: 70Race: HispanicGender: MaleClinical Information

 

1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–           15 minutes

–          Clinic visit

–          Numbness in the extremities

–          Lifestyle

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Metformin

–          Metformin

ICD 10 CodesE11 CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

–          99213

–          83036

Other Questions 1.      Age range –  elderly adult

2.      Patient type –   outpatient

3.      HPI – diabetic, fatigue, weight loss, numbness in the extremities

4.      Patients primary language – English

5.      Chart on patient record –   yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit – yes

 

Clinical Notes1.      Chief complaint – numbness in the extremities

Diagnoses

2.      Plan –  clinical assessment

o   findings – pigmented pretibial patches, reduced visual acuity, lung auscultation within normal limits, normal heart sounds, no abdominal distention or tenderness, and bilateral sensory loss in the lower and upper extremities

3.      Diagnostic –  Glycated hemoglobin (A1C) test

4.      Therapeutic – Metformin 2000 mg per day divided in two doses

5.      Education –  Engage in physical activity, cease alcohol consumption, reduce fats, sugar, and carbohydrates, eat a lot of vegetables, and drinking sufficient water every day

6.      Collaborated – collaborated with endocrinologist during patient care

Bone Mass Density Screening 9/12done

Patient Demographics

 

Age: 71Race:  LatinoGender:  Male Clinical Information

 

1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

– 10 minutes

– preventive medicine

– none

– lifestyle

 

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          None

–          None

ICD 10 CodesZ13.820 CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

–          99201

–          77080

Other Questions 1.      Age range –  elderly

2.      Patient type –   outpatient

3.      HPI – none

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

Clinical Notes1.      Chief complaint – no presenting chief complaint

Diagnoses

2.      Plan – physical assessment

o   findings – normal muscle tone, no fracture observed, no buffalo hump, no kyphoscoliosis, normal back posture, no hepatomegaly, mild central obesity, no hepatomegaly, no striae, normal thyroid tone and size

3.      Diagnostic –  bone density test (dual energy x-ray absorptiometry) of the hip and spine

Results – T-score: 0.9

4.      Therapeutic – no medication prescribed

5.      Education – nutritional education including intake of foods rich in calcium and regular strength exercise to maintain health and wellbeing

6.      Collaborated – collaborated with orthopedist during patient evaluation

Rheumatoid Arthritis 9/12done

Patient DemographicsAge: 73 yearsRace:   non-Hispanic WhiteGender: FemaleClinical Information 1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          30 minutes

–          Problem-focused visit

–          Joint pain and swelling

–          Behavior change

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          None

–          oral Leflunomide

ICD 10 CodesM06.9 CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

–          99203

–          76881, 73120, 85027

Other Questions 1.      Age range –  elderly adult

2.      Patient type –  outpatient

3.      HPI –  tender, warm, swollen joint, joint stiffness usually worse in the morning, fatigue, anorexia

4.      Patients primary language – English

5.      Chart on patient record –   yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit – yes

Clinical Notes1.      Chief complaint – tender swollen joint

Diagnoses

2.      Plan – clinical evaluation

o   findings – low-grade fever (99.2 F), rheumatoid nodule over metacarpophalangeal joints, atrophy of digital skin, rice paper skin, scleritis, decreased breath sounds, splenomegaly, red swollen joint with tenderness on palpation, painful on movement, and decreased range of motion

3.      Diagnostic –  joint Xray, ultrasound, erythrocyte sedimentation blood test

4.      Therapeutic – 1*1 PO Leflunomide100mg for 3 days, AND Leflunomide 20mg q24h maintenance dose

–          Heat compresses to reduce swelling

5.       Education – proper nutrition, and physical activity to address obesity

6.      Collaborated – collaborated with orthopedist during patient management

Routine Hearing Test9/12done

Patient Demographics

 

Age: 80Race:  Pacific IslanderGender: FemaleClinical Information 1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          10 minutes

–          Preventive test

–          None

–          Lifestyle change

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 

–          None

–          None

–          None

ICD 10 CodesZ01.110CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

–          99201

–          92550, 92552

Other Questions 1.      Age range – elderly adult

2.      Patient type – outpatient

3.      HPI – none

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

 

Clinical Notes1.      Chief complaint  – routine hearing test without presenting complaint

Diagnoses

2.      Plan – ear exam

o   Findings – no ear impaction, no ear discharge, no swelling, flexible eardrum

3.      Diagnostics – tympanometry, audiometry

4.      Therapeutic – none

5.      Educational: avoid exposure to excessive noise and adherence to routine checks

6.      Collaboration – collaborated with audiologist during screening

Gynecomastia 9/12done

Patient Demographics

 

Age: 67Race:  African AmericanGender:  maleClinical Information 1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          20 minutes

–          Problem-focused visit

–          Pain in the breast region

–          Behavioral

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 

–          None

–           None

–          Testosterone replacement

ICD 10 CodesN62CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

 

–          1000F, 2000F, 4000F,99202

–          82670, 77066, 18944,

Other Questions 1.      Age range – elderly adult

2.      Patient type – outpatient

3.      HPI – increased breast size

4.      Patients primary language – English

5.      Chart on patient record- yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

 

Clinical Notes1.      Chief complaint – tenderness in the breast area

Diagnosis

2.      Plan – breast exam

o   Findings – enlarged breast tissue, tenderness

3.      Diagnostics –  blood test, estrogen-to-androgen laboratory test, mammograms

Results – no malignancy, reduced testosterone levels

4.      Therapeutic – short duration testosterone replacement therapy

5.      Educational – reduced alcohol consumption and cessation heroin

6.      Consultation – consulted with urologist and endocrinologist

 

 Herpes Zoster Vaccination 9/12done

Patient Demographics

 

Age: 65Race:  GermanGender: femaleClinical Information 1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          10 minutes

–          Preventive visit

–          No presenting complain

–          Healthy habits

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 

–          None

–          None

–          Shingrix vaccine

ICD 10 CodesZ23CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

 

–          99201

–          90750, 85027

Other Questions 1.      Age range – elderly adult

2.      Patient type – outpatient

3.      HPI – none

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

 

Clinical Notes1.      Chief complaint – no presenting complain

            Diagnosis

2.      Plan – clinical assessment

o   Findings – BMI 25, pulse and blood pressure within normal range, no hearing loss, good vision, no lung crackles, no tachypenia, no heart murmurs, no abdominal distension and tenderness, normal genito-urinary assessment results

3.      Diagnostics – complete blood count

4.      Therapeutic – Shingrix vaccination 1 dose

5.      Educational – healthy living habits, including moderate strength workout, proper nutrition, and stress avoidance

6.      Collaboration – collaborated with geriatric physician during patient care

 Parkinson’s Disease9/12done

Patient Demographics

 

Age: 69Race:  WhiteGender: maleClinical Information 1.      Time with patient

2.      Reason for visit

3.      Chief Complaint

4.      Social problems addressed.

–          15 minutes

–          Consultation visit

–          Tremor

–          Behavioral

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

 

–          None

–          None

–          carbidopa-levodopa

ICD 10 CodesG20 CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

–          99215

–          95831, 76506, 78607

Other Questions 1.      Age range – elderly adult

2.      Patient type – outpatient

3.      HPI – speech changes, loss of automatic movement, rigid muscles, bradykinesia, impaired posture, head trauma about 10 years ago

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

 

Clinical Notes1.      Chief complaint  – tremor in the limbs

Diagnosis

2.      Plan – physical and neurologic examination

o   Findings – reduced facial expression, olfactory dysfunction, jaw tremor, neck tightness, abdominal distention, dribbling of urine, bradykinesia, shuffing gait, and cogwheel rigidity

3.      Diagnostic  – brain ultrasound, neurology, and dopamine transporter scan

4.      Therapeutic –carbidopa-levodopa 10mg/100 mg PO q8hr initially; levodopa increased by 100mg/day every 2 days up to 800mg/day.

5.      Educational – Healthy dietary habits and moderate exercise

6.      Collaboration – collaborated with neurologist during patient care

7.      Collaboration – collaborated with neurologist during patient evaluation and management

 

Blood Pressure Testing 9/12done

Patient Demographics

 

Age: 66Race:  Latin AmericanGender:  femaleClinical Information 1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          10 minutes

–          Follow-up visit

–          Blood pressure monitoring

–          Behavioral change

 

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Oral hydrochlorothiazide

–          Oral hydrochlorothiazide

ICD 10 CodesZ01.30 CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

–          99212

–          81000, 93010

Other Questions 1.      Age range – elderly

2.      Patient type – outpatient

3.      HPI –  previously diagnosed with hypertension

4.      Patients primary language – English

5.      Chart on patient record –  yes

6.      Discussed management with the preceptor handled visit independently –  yes

7.      Preceptor present during visit –  yes

 

Clinical Notes1.      Chief complaint – blood pressure monitoring with no presenting complaint

Diagnoses

2.      Plan – cardiovascular assessment

o   findings –  BP of 144/94 mmHg, a pulse rate of 98 bpm, left parasternal heave, loud P2 component of S2, diastolic murmur, panystolic murmur, ejection midsystolic murmur, pulsative liver,

3.      Diagnostic – urinalysis , electrocardiogram

4.      Therapeutic – Oral hydrochlorothiazide 50mg single dose per day

5.      Education –  eat food low in fat and carbohydrates, increase physical activity, reduce salt intake, maintain healthy BMI, reduce or cease alcohol consumption and cigarette smoking, adhere to medication, and manage stress

6.      Collaborated – collaborated with cardiologist during patient care

Generalized Lymphadenopathy 9/14done

Patient DemographicsAge: 69Race:  African AmericanGender:  FemaleClinical Information1.      Time with patient

2.      Reason for visit

3.      Chief complaint

4.      Social problems addressed

–          10 minutes

–          Problem focused

–          Enlarged lymph nodes

–          behavioral change

Medications1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          None

–          Lamivudine 300mg once daily

ICD 10 CodesB23.1CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

–           99213

–          86701, 86360

Other Questions 1.      Age range – elderly adult

2.      Patient type – outpatient

3.      HPI – persistent swelling of lymph nodes, skin rash

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

 

Clinical Notes1.      Chief complaint  – enlarged lymph nodes

            Diagnosis

2.      Plan – clinical exam

o   Findings – tender anterior cervical, posterior cervical, tonsillar, sub mandibular, and supra-clavicular lymph nodes on palpation

3.      Diagnostics –  blood test, CD4 count

Results – HIV positive, CD4 count of 190

4.      Therapeutic: Lamivudine 300mg once daily

5.      Educational: proper nutrition, adherence to medication, ample rest, and physical activity, safe sex practices

6.      Collaboration – collaborated with immunologist during patient management

 

Prostate Cancer Screening 9/14done

Patient DemographicsAge: 68Race:  Pacific IslanderGender: maleClinical Information

 

1.      Time with patient

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          10 minutes

–          Preventive visit

–          None

–          Behavioral

Medications 1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Aspirin

–          None

ICD 10 Codes

 

Z12.5CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

 

–          99201

–          84153

 

Other Questions 1.      Age range – elderly adult

2.      Patient type – outpatient

3.      HPI – no presenting symptoms

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

 

Clinical Notes1.      Chief complaint – preventive visit with no presenting complaint

Diagnoses

2.      Plan – physical and digital rectal exam

o   Findings – no bladder distention, no suprapubic palpation of the bladder, no tenderness, no asymmetrical boggy mass on digital rectal exam

3.      Diagnostics – prostate-specific antigen (PSA) test

–          Results – 3.7 ng/mL PSA results

4.      Therapeutic – no medication prescribed

5.      Educational – physical exercise and healthy feeding to incorporate food types low in fat, and high in fiber and antioxidants

6.      Collaboration – collaborated with oncologist during patient assessment

Alzheimerdone9/21done

Patient DemographicsAge: 75Race:  American LatinoGender: femaleClinical Information1.      Time with patient

2.      Reason for visit

3.      Chief complaint

4.      Social problems addressed

–          45 minutes

–          Consultation

–          Cognitive impairment

–          Behavioral

Medications1.      OTC medications taken regularly

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Razadyne

–          donepezil and dextroamphetamine

ICD 10 CodesG30.9 (F02.80)CPT Billing Codes1.      Evaluation and management

2.      Provider procedure codes

–          99213

–          96119, 78811

Other Questions 1.      Age range – elderly adult

2.      Patient type – outpatient

3.      HPI – Memory loss that began two months ago

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Clinical Notes1.      Chief complaint  – cognitive impairment and memory loss

Diagnosis

2.      Plan – mini-mental status examination

o   Findings – moderate cognitive impairment, difficult concentrating, inattentive, poor judgment

3.      Diagnostics – neuropsychological testing , fluorodeoxyglucose (FDG) PET scan

4.      Therapeutic – 5 mg donepezil PO QD AND dextroamphetamine 5mg PO BID

5.      Educational – exercise, nutrition, adequate supervision, following up with prescription, and safe environment

6.      Collaboration –  consulted with psychiatric during patient

 

 

---

Solution: