Pediatric Soap Notes Assignment Discussion
Running head: PEDIATRIC SOAP NOTES Pediatric Soap Notes Student’s Name Institutional Affiliation 1 PEDIATRIC SOAP NOTES 2 Pediatric Soap Notes A. Respiratory Synctial Virus (RSV) Prophylaxis Patient Demographics Age: 2 Race: Hispanic Gender: Male Clinical Information 1. 2. 3. 4. Time with patient Reason for visit Chief Complaint. Social problems addressed. – 15 minutes – preventive medicine – RSV prevention – behavioral Medications 1. OTC medications taken regularly 2. Prescriptions currently prescribed 3. New/refilled prescriptions ICD 10 Codes B97.4 CPT Billing Codes 1. 2. 3. 4. 5. 6. 7. 1. Evaluation and management Pediatric Soap Notes Assignment Discussion
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2. Provider procedure codes Other Questions – – None None Palivizumab 99213, 1000F, 2000F, 3006F 97760 Age range – toddler Patient type – outpatient HPI – hemodynamically significant congenital disease Patients primary language – English Chart on patient record – yes Discussed management with the preceptor handled visit independently – yes Preceptor present during visit – yes Clinical Notes 1. Chief complaint – hemodynamically significant congenital disease Diagnoses 2. Plan – Lungs exam o findings – wheezing and cough 3. Diagnostic – pulse oximetry 4. Therapeutic – Palivizumab (synagis) 15 mg per kg IM q monthly all through winter 5. Education – wash hands before handling the child, keep surfaces disinfected, discourage sharing of utensils, and limit contact with those with cold-like symptoms Pediatric Soap Notes Assignment Discussion