– Soapnote5.txt

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Semester:SpringCourse:MSN6150C Advanced Practice PediatricsPreceptor:REYES-CHOUZA, CARLOSClinical Site:IDEAL MEDICAL CENTERSetting Type:Underserved area/populationPatient DemographicsAge:4 yearsRace:HispanicGender:MaleInsurance:MedicaidReferral:No referralClinical InformationTime with Patient:20 minutesConsult with Preceptor:10 minutesType of Decision-Making:Low complexityReason for Visit:EpisodicChief Complaint:Mother states” my kid have a white patches on his mouthType of HP:DetailedSocial Problems Addressed:Sanitation/HygieneSafetyEducation/LanguageNutrition/Exercise Procedures/Skills (Observed/Assisted/Performed)Physical Assessment – Physical Assessment (Perf)General Skills – Vital Signs (Perf)ICD-10 Diagnosis Codes#1 – B37.0 – CANDIDAL STOMATITISCPT Billing Codes#1 – 99213 – OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MINBirth & DeliveryMedications# OTC Drugs taken regularly:0# Prescriptions currently prescribed:0# New/Refilled Prescriptions This Visit:1Types of New/Refilled Prescriptions This Visit:Infectious Diseases – Antimycotics, systemic Adherence Issues with Medications:Other:  Other Questions About This CasePatient’s Primary Language:SpanishSmoking Assessment:NeverAdvanced Directive:NoPacks per day:

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