Create a patient. Give background of patient based on what you would learn from the a patient intake. In other words age, lifestyle, general well-being.

Create a patient. Give background of patient based on what you would learn from the a patient intake. In other words age, lifestyle, general well-being. Put in some information about diet exercise just how the individual treats themselves. Please include past medical history and previous treatments (ex: medications) Dont get too carried away, in real life patients do not always give much detail here.

So with patient background you will put together a SOAP note:

Quick physical assessment will be done: Height, weight, BP, Resp rate, Temp. Duration.

S subjective. This is what the patient tells you. Why they are there (if they are able to, sometimes they are not conscious and you have to rely on who came in with them) This is symptoms.

O – objective. This is what you see and what you test for. Rashes, labored breathing, blood test imaging any study results.

A – assessment. This is your diagnosis. What you feel the patient has. Might be more then one condition. (put in why you selected this) Put in ICD-10 codes.

P- Plan. What is your treatment for this or these conditions. Expected outcomes, problems reaching this outcome, follow up care. Treatment includes medication and therapy. Include CPT codes.

You have a lot of leeway with this project.

Realize you are writing this with not a lot of time. You need to be precise and to the point. Insurance uses this to justify payment. This is important but you have a lot of patients and not a lot of time.