Create 10 women’s Health Soap notes.

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Create 10 women’s Health 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(birth control consult, annualexam and Pap smear, pertaining only to this population.Every soap note needs a diagnosis and therapeutic section must have medications and prescribing instructions

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:

include pelvis exam findings
Diagnostics:
Therapeutics:include full prescribing information
Education:

Consultation/Collaboration: