Herzing University Pediatric Soap Notes from an FNP Perspective Paper

Herzing University Pediatric Soap Notes from an FNP Perspective Paper

Create 12 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, 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.Include low to medium complexity in ICD code.
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: