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

 

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