FNP 1 Encounter soap notes day 3 and 4
I need 20 pt. encounter notes like the sample below each have to be of a different pt. and case. It has to be of a pt. visiting a primary care physicians office not a hospital. Pts. must be between ages 18-78. ICD and CPT codes must be included and can be found with these links provided, https://www.findacode.com/index.html https://www.aapc.com/codes/em-calculator-2021/
Sample SOAP NOTE Below:
S: Patient presents for anxiety follow-up visit. Patient was last seen 3 months ago after starting Prozac 20mg daily. At that time patient noticed slight changes in anxiety symptoms but was still having 13-15 panic attacks per week. Patient was given Rx for PRN Ativan 0.25mg. At this current visit patient states that his anxiety symptoms have significantly subsided but still experiences anxiety on a daly basis. His panic attacks have cut down to 2/wk. He has been using the RN Ativan during panic attacks but reports he needs to take double the dose. Patient also reports he is on the search to find a therapist, but the thought of speaking in person to someone new gives his great anxiety.
O: BP 143/73 (machine); recheck 122/85 (manual), T 97.8, P 78, RR 18, SA02 98%
A: Generalized Anxiety Disorder with Panic Attacks (ICD and CPT codes)
P: Provider offered to increase Prozac dose in hopes to cut back on the PRN Ativan. Patient requests Prozac dose not to be changed at this time. Patient educated on starting with 0.25mg Ativan, and waiting 30 minutes before taking 2nd dose. Prescriptions refilled. Patient encouraged to establish care with a therapist; offered Telehealth therapist site to establish a virtual visit. Follow-up in 3-4 weeks for anxiety reassessment and to see if medication dosages need to be adjusted.
Also list ICD Code and CPT code for your diagnosis; example ICD for GAD is F41.1 and CPT code for a visit of this type would most likely be a 99213