Geriatric Soap Notes from an FNP Perspective Sample

Patient Demographics

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Consultation

–          Persistent feeling of sadness

–          Behavioral

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Sertraline

2.      Provider procedure codes

–          96127, 84439

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

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

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Clinic visit

–          Numbness in the extremities

–          Lifestyle

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          Metformin

–          Metformin

2.      Provider procedure codes

–          83036

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

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

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

– preventive medicine

– none

– lifestyle

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          None

2.      Provider procedure codes

–          77080

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

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

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Problem-focused visit

–          Joint pain and swelling

–          Behavior change

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          oral Leflunomide

2.      Provider procedure codes

–          76881, 73120, 85027

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

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

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Preventive test

–          None

–          Lifestyle change

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          None

2.      Provider procedure codes

–          92550, 92552

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

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

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Problem-focused visit

–          Pain in the breast region

–          Behavioral

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–           None

–          Testosterone replacement

2.      Provider procedure codes

–          82670, 77066, 18944,

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

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

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Preventive visit

–          No presenting complain

–          Healthy habits

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Shingrix vaccine

2.      Provider procedure codes

–          90750, 85027

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

            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

2.      Reason for visit

3.      Chief Complaint

4.      Social problems addressed.

–          Consultation visit

–          Tremor

–          Behavioral

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          carbidopa-levodopa

2.      Provider procedure codes

–          95831, 76506, 78607

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

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

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Follow-up visit

–          Blood pressure monitoring

–          Behavioral change

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          Oral hydrochlorothiazide

–          Oral hydrochlorothiazide

2.      Provider procedure codes

–          81000, 93010

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

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

2.      Reason for visit

3.      Chief complaint

4.      Social problems addressed

–          Problem focused

–          Enlarged lymph nodes

–          behavioral change

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Lamivudine 300mg once daily

2.      Provider procedure codes

–          86701, 86360

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

            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

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Preventive visit

–          None

–          Behavioral

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          Aspirin

–          None

2.      Provider procedure codes

–          84153

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

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

2.      Reason for visit

3.      Chief complaint

4.      Social problems addressed

–          Consultation

–          Cognitive impairment

–          Behavioral

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          Razadyne

–          donepezil and dextroamphetamine

2.      Provider procedure codes

–          96119, 78811

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

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