Soap Note For Older Adult Nursing Home Patient
Question Description
Hello follow instruction, please can you use these ICD-10 Codes and diagnosis to make up 10 Soap notes with each of them for older adult patients or residents age 50 year old and up currently living in a Nursing Home Facility or Long Term Care Patients. Below is a sample of what to include in the notes how to do the soap notes. Use different age, Vital sign, sex, Mental status, weight, inches, BMI, ECT…… and information for each soap notes.
This is the sample of what to include in the notes:
Location: Nursing Home
Mental Status
Age: From 50 year old and up 69 years
Sex: Female and male
Height:
Weight: in LBS
BMI
Temperature:
Pulse:
Blood pressure:
Respiratory rate:
SpO2: on room air
Allergies:
Chief complaint:
HPI:
Past Medical History:
Immunization.
Rx (medications
FHx (family history):
Smoking
SHx (social history) SHx (social history)
Plan
Preventive Health:
Teaching
10) M62.81 Muscle weakness (generalized)
R26.2 Difficulty in walking, not elsewhere classified
Congestive heart failure, unspecified I50.20
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart
failure
I50.30 Unspecified diastolic (congestive) heart
Failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart
failure