Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)

Semester: Spring Course: MSN6150C Advanced Practice Pediatrics Preceptor: REYES-CHOUZA, CARLOS Clinical Site: IDEAL MEDICAL CENTER Setting Type: Underserved area/population Patient Demographics Age: 4 years Race: Hispanic Gender: Male Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 20 minutes Consult with Preceptor: 10 minutes Type of Decision-Making: Low complexity Reason for Visit: Episodic Chief Complaint: Mother states” my kid have a white patches on his mouth Type of HP: Detailed Social Problems Addressed: Sanitation/Hygiene Safety Education/Language Nutrition/Exercise   Procedures/Skills (Observed/Assisted/Performed) Physical Assessment – Physical Assessment (Perf) General Skills – Vital Signs (Perf) ICD-10 Diagnosis Codes #1 –  B37.0 – CANDIDAL STOMATITIS CPT Billing Codes #1 –  99213 – OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN Birth & Delivery Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 1 Types of New/Refilled Prescriptions This Visit: Infectious Diseases – Antimycotics, systemic   Adherence Issues with Medications: Other:   Other Questions About This Case Patient’s Primary Language: Spanish Smoking Assessment: Never Advanced Directive: No Packs per day: