Soap Note (Due 6 hours)

  

1) ************Complete the template attached (See File 1) according to the example (See File 2 )   

               It is mandatory that you respect the information requested in the template

              You should not modify the template. The titles and subtitles will be verified

2)¨******APA norms  

            Dont write in the first person 

            Dont copy and pase the questions.

            Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

3) It will be verified by Turnitin and SafeAssign

4) Minimum 5 references not older than 5 years

_______________________________________________________________

Patient:

Name: AN

 Age:

36 years

Race:

White, Non Hispanic

Gender:

Female

Insurance:

Private insurance

Referral:

No referral 

 Chief Complaint

“Headache 

 ICD-10 Diagnosis Codes

G43.011 – MIGRAINE WITHOUT AURA, INTRACTABLE, WITH STATUS MIGRAINOSUS 

 CPT Billing Codes

99204 – OFFICE/OP VISIT, NEW PT, 3 KEY COMPONENTS:COMPREHENSIVE HX;COMPREHENSIVE EXAM;MED DECISN MOD COMPLEX 

Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic – NSAIDS
Neurology – Migraine