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How to write a soap note for nurse practitioners

15/04/2021 Client: muhammad11 Deadline: 2 Day

You are a FNP running a rural clinic as their healthcare provider. Documentation is important to paint the picture of your time spent with the patient. Your patients are adult only with the ages ranging from 19-70. Create 38 different SOAP notes. Addressing different systems of the body. The best way to complete this assignment would be to assign by groups for example 6pts/Cardiovascular -chf. In your soap template include medications, ICD 10 diagnosis codes ,CPT billing codes and referrals if needed. Attached you will have sample of the templates used. No need to have in text citations or references.Please follow format. Below are the textbooks used.SOAP SAMPLE 1: Age: 45 years Race: Black or African American Gender: Female Insurance: PPO Referral: Allied Health Clinical Information Time with Patient: 60 minutes Consult with Preceptor: Type of Decision-Making: Low complexity Student Participation: Primary (>50%) Reason for Visit: Episodic Chief Complaint: Pt. noted heart palpitations lasting 15 min x1 wk. Encounter #: 1 Type of HP: Problem Focused Social Problems Addressed: Nutrition/Exercise Other: stress management Procedures/Skills (Observed/Assisted/Performed) General Skills - Determine heart rate (Perf) General Skills - Palpate thyroid (Perf) Specialty Skills - Cardiovascular risk assessment/management (Perf) Specialty Skills - EKG interpetation (Perf) ICD-10 Diagnosis Codes #1 R07.9 - CHEST PAIN, UNSPECIFIED #2 I20.9 - ANGINA PECTORIS, UNSPECIFIED CPT Billing Codes #1 85025 - BLOOD COUNT; COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, & PLATELET) & AUTOMATED DIFFERENTIAL WBC #2 93351 - ECHOCARDIOGRAPHY, TRANSTHORACIC R-T 2D -+M-MODE REST&STRS CONT ECG #3 93018 - CARDIOVASCULAR STRESS TEST W/ECG MONITOR; INTERPRETATION & REPORT ONLY #4 80053 - COMPREHENSIVE METABOLIC PANEL #5 80050 - GENERAL HEALTH PANEL #6 84484 - TROPONIN, QUANTITATIVE #7 84512 - TROPONIN, QUALITATIVE Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 1 # New/Refilled Prescriptions This Visit: 0 Types of New/Refilled Prescriptions This Visit: Adherence Issues with Medications: Other Questions About This Case Age Range: 36 - 65 years Clinical Setting: Private Office Patient Type: Female History of Patient Illness (HPI): Pt. states that the palpitations “come and go― Pt. noted heart palpitations lasting 15 min x1 wk. Pt Patient Education: Try reducing caffeine from coffee, etc. If that does not work, try lowering dose of Adderall XR. Loo Patients Primary Language: Time spent performing family assessment: Other: Alcohol use or abuse disorder: Breast exam: Cervical exam: Diabetic consultation: Did you chart on patient record?: Yes Discussed management with preceptor: Yes Domestic violence assessed: History of tobacco use: Handled visit independently: Preceptor present during visit: Yes Lab review: Newborn assessment: Early postpartum visit <1 week:> Mental health referral: Contraception visit: Clinical Notes S:45 y/o african american f. pt. presents w/ palpitations x1 year (progressively worsening x6 months). Pt. states that the palpitations "come and go" Pt. noted heart palpitations lasting 15 min x1 wk. Pt. ?reports that it "feels like a little thump right over her heart." Pt. rated discomfort as a 5-7/10. Pt. denies that pain radiates. Pt. states no aggravating / alleviating factors. Pt. denies SOB, CP, LOC, dizziness, and light headedness. Pt. takes 20mg Adderall XR x30 years and drinks coffee 6 to 8 cups / day increased recently. Pt. indicated that she thought it may

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