write a soap note for a women who comes to the clinic with a chief complaint of “increased vaginal discharge and fishy smell.”
Universal SOAP Note Template Student’s Name: Gender: Comment: Date: Male Age: Date of Birth: Ethnicity: Female SUBJECTIVE DATA Chief Complaint (CC) History of Present Illness (HPI) **GYN Focus** In patient’s own words. Identity and reliability of informant if patient is not informant. Must include Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, and Severity (OLDCARTS). Include pertinent positives from the review of systems as they relate to the HPI. OB/GYN history Gravida/Para. Last menstrual period. Last PAP w/ results. Last Mammogram w/ results. Sexual History History of STD, last sexual partner, sexual history, birth control hx, sexual orientation, Past Medical History (PMH) In chronological order: Current/Past medical problems with date of onset Past Surgical History (PSH) 1 In chronological order: Surgeries and Procedures with date performed and outcome Immunizatio n status Age specific immunizations, list and describe any history of reactions Medications **birth control** Current medications: include medication name, dose, route, frequency, duration, and reason for taking 2 Allergies Medications, Foods, Environmental, Latex and how allergy is manifested Family History (FH) Blood relatives: Age, living/deceased, medical problem. Include grandparents, siblings, children Social History (SH) (marital status, children), Lifestyle risk factors (illicit drug use, smoking/pack year, exercise) , Employment history, Education, Religion – beliefs, Cultural history, Support System, Stressors, Driving Review of Systems (ROS) Constitution al General statement by the patient (reported symptoms that do not fit one system but often affect overall status) Skin Eyes, Ears, Nose Throat/Mout h Cardiovascu lar Respiratory 3 Gastrointesti nal Reproductiv e / Genitalia / Genitourina ry Breast/Lymp hatics Musculoskel etal Neurological OBJECTIVE DATA Physical Exam General/Constitutio nal General description of patient including age, gender, nutritional status, habitus, attention to grooming, state of cooperativeness/demeanor, overall picture of wellness/distress Vital Signs Temperature, Pulses (apical and radial), Respirations, BP (Ht, Wt, BMI) Skin HEENT Neck Respiratory Cardiovascular 4 Breast/Lymphatics Abdomen Female Genitourinary/ GYN Rectal Vulvar Exam: Speculum Exam: • Cervical Exam: Bi-manual Exam: (Describe all assessment findings for each portion of the GYN exam, if portion of exam was not one- please document “deferred”) Rectal Exam: Musculoskeletal Including frailty evaluation if applicable Neurological (Mental Status, Cranial nerves, Motor, Cerebellum, Motor, Cerebellum, Sensory, Reflexes) Diagnostic Information Results of diagnostic testing conducted at the time of the visit OR previously done and being used to support the diagnosis and management plan for the current visit 5 DIFFERENTIAL DIAGNOSES AND SUPPORTING DATA 3 differential diagnoses for each presenting problem (Population specific wellness exam if no problems identified) Data in your assessment that supports or rules out this diagnosis Final ICD 10 diagnosis codes for the current visit ICD 10 Code 1. Corresponding Diagnosis 2. 3. 4. 5. 6 TREATMENT PLAN (For graded SOAP note submissions, include rationale for all components of treatment plan and support with citations from peer-reviewed information) Additional Diagnostic tests needed Treatments: Pharmacological Treatments: NonPharmacological Patient Education Consultations recommended with Rationale Return to Clinic/FollowUp Next office visit scheduled, identify the plan for follow-up, note expectations for further treatment. 7 CPT Billing Codes Reflected in the Treatment Plan CPT Code Corresponding Diagnosis 1. 2. 3. 4. 5. 8 FNP Student West Coast University Patient Name _____________________________________ Date ___________________ Rx Refill NR 1 2 3 4 5 Signature ____________________________________________________________ 9 Discussion: (for Problem-focused SOAP notes ONLY) Please provide a 1-2 paragraph discussion on your case. This can be why you chose the specified/prescribed treatment plan, the pathophysiology of the assessment, why you referred the patient for a specific diagnostic test, etc. References: Please use at least three current (within 5 years) guidelines, articles, or textbook. Please list. 10
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
