Women health SOAP notes - It is recommended to include

Women health SOAP notes

Delete all text in red - these are instructions and not part of the SOAP document.

SOAP Note women annually wellness exam

Requirement:

APA format

Intext citation

References at least 4 high-level scholarly reference per post within the last 5 years in APA format.

EACH differential diagnostic gets 1 reference

ID:

Client’s Initials*Age 35 Race Gender female Date of Birth___________

Insurance _______________ Marital Status_____________

*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect client confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.

Subjective:

CC: “ I came for my yearly physical examination”

HPI:

Patient is a 35 year old female, came to the office for her annual wellnes exam. She feels perfectly fine. She mentioned that noticed before menstruation comes every month she has painful breast ,bilateral and noticed some lumps in her both breast, but more in her right breast.

Past Medical History:

· Medical problem list

· Preventative care: (if applicable to the case – Pap smear, mammography, colonoscopy, dates of last visits, etc.)

· Surgeries:

· Hospitalizations:

· LMP, pregnancy status, menopause, etc. for women

Allergies:

Food, drug, environmental

Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use

Family History:

Social History:

-Sexual history and contraception/protection (as applies to the case)

-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here - what is pertinent and necessary for safe and holistic care)

ROS (write out by system): Comprehensive ( >10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed - review and document the pertinent systems. Do not include diagnoses - those belong in PMH. The below categories are per CMS guidelines.

Constitutional:

Eyes:

Ears/Nose/Mouth/Throat:

Cardiovascular:

Pulmonary:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary & breast:

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective

Vital Signs: HR BP Temp RR SpO2 Pain

Height Weight BMI

Labs, radiology or other pertinent studies: be sure to include the date of labs - might be POC tests from today

Physical Exam (write out by system):

Start with a general survey:

Assessment

(you will often have more than one diagnosis/problem, but do the differential on the main problem)

Differentials (with a brief rationale and references for each one:

1. Wellness visit:

2. Fibrocystic changes of breast:

3. Fibroadenoma of the breast:

Diagnosis

Plan (3 pronged-plan for each problem on the problem list) use clinical guidelines to develop treatment plans for your patients

Diagnostics:

Treatment: (please use Guidelines reference) use clinical guidelines to develop treatment plans for your patients

Education

Follow Up:

List plan under each Diagnosis.

Example

1: Hypertension (I10)

A: Lisinopril/HCT 20/12.5 Daily #90, refills 3

B: BMP in 6 months

C: Recheck BP in 2 Weeks

D: Low Sodium Diet and lifestyle modifications discussed

2: Morbid Obesity BMI XX.X (E66.01)

A: Goal of 5% weight reduction in 3 months

B: Increase exercise by walking 30 minutes each day

C: Portion Size Education

3: T2 Diabetes with diabetic neuropathy (E11.21)

A: Repeat A1C in 3 months

B. Increase Metformin to 1000mg BID #180, refills: 3

C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)

D: Daily blood glucose check in the am and when sick

E. Return to clinic in 3-4 months to reassess