SOAP Note for IUD Insertion

SOAP Note for IUD Insertion

his one is the 2nd case log for the second Soap note;

Age: 30 years
Race: White, Non Hispanic
Gender: Female
Insurance: No insurance
Referral: No referral
Clinical Information
Time with Patient: 45 minutes
Consult with Preceptor: 15 minutes
Type of Decision-Making: Low complexity
Student Participation: Less than shared
Reason for Visit: Episodic
Chief Complaint: I came for the labs review and for a IUD insertion
Encounter #: 1
Type of HP: Problem Focused
Social Problems Addressed: Sanitation/Hygiene
Safety
Issues w/Community Resources
Emotional
Sexuality
Prevention
Nutrition/Exercise
Procedures/Skills (Observed/Assisted/Performed)
General Skills – Breast exam (Asst)
General Skills – Immunizations (Asst)
General Skills – Interpret lab studies (Asst)
General Skills – Pap smear (Asst)
General Skills – STD & HIV screening/counseling (Asst)
ICD-10 Diagnosis Codes
#1 – Z30.8 – ENCOUNTER FOR OTHER CONTRACEPTIVE MANAGEMENT
#2 – Z01.419 – ENCNTR FOR GYN EXAM (GENERAL) (ROUTINE) W/O ABN FINDINGS
CPT Billing Codes
#1 – 99203 – OFFICE/OP VISIT, NEW PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 30-44 MIN
#2 – 2010F – VITAL SIGNS DOCUMENTED AND REVIEWED
#3 – 99071 – PATIENT EDUCATION MATERIALS PROVIDED BY PHYSICIAN/OTHER PROFESSIONAL
#4 – 58300 – INSERTION, INTRAUTERINE DEVICE
Birth & Delivery
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic – NSAIDS		 Adherence Issues with Medications:
Other Questions About This Case
Nutritional Status: Good
Smoking Assessment: Former Smoker
Trimester:
Patient’s primary language: Spanish
Ethnicity: Spanic/Latin
History of present illness (HPI): #0 y/o female who comes today for a IUD insertion
Other current meds/herbals/vitamins: multivitamins
TIme spent performing family assessment: 5
Blind :
Deaf:
Screen for drugs: Yes
Screen for alcohol: Yes
Homeless:
Religious practices affecting care:
Immunizations up to date: Yes
Patient is non-ambulatory:
Patient is ambulatory: Yes
Antepartum new:
Peri/postmenopausal visit:
Breastfeeding eval and counseling:
Early postpartum visit < 1 week:
Home birth:
Newborn assessment:
Clinical Notes
CC: I came for the lab’s review and for an IUD insertion
HPI: 30 y/o female who comes today to check the labs for the IUD insertion as birth control.. G3T2P2A1L2.
Medication: levothyroxine 125mch daily
NKA
Viatls BP 120/60 ( manual) HR: 67, RR 19, temp: 97.5

Review of systems:
ROS: General: The patient denies any memory problems, no headache. denied visual, or hearing loss, or reading glass use, denies tingling, or numbness, no muscle weakness, pt denies walking problems and No mood changes. No psychiatric problems.
HEENT: Pt Denies any ear, or neck pain. Pr denies visual problems. Pt denies nasal, denies nose bleeding, or tooth pain. Patient denies sore throat but states good smell and sense of taste. Pt denies Thyroid problems.
Cardiovascular: Pt denies hypertension, and denies chest pain, shortness of breath, palpitations, no leg pain. No skin color change. No edema, no cyanosis.
Respiratory: Pt denies shortness of breath, or fatigue, no cough, denies chest pain. No sputum production.
GI: Pt denies any retrosternal pain, no nausea or vomiting, no diarrhea, no blood in the stool, denies constipation and states regular daily BM.
GU: The patient denies dysuria during or Nycturia and even he denies blood in the urine. Ptdenies heavy vaginal bleeding during her regular periods.

Musculoskeletal: No pain or difficulty walking and no muscle weakness. Spine with no problems.
Physical exam:
General. Pt came walking normal, and appearance, well-groomed, alert, and oriented to person, time, place and situation, normal speech. No distress notice, normal mood.
HEENT: head normal, normal hair implantation and distribution, for the age, ear normal implantation with no pain at palpation, no drainage, normal tympanic membrane. Nasal mucosae pink and moist, no pain on pressure over the frontal and maxillary sinus. Red eyes, no secretion noted, no nystagmus, PERRLA, normal eye movements in all quadrants. Neck flexible, no mass, no nodules, thyroid no visible not palpable.
Cardiovascular: Normal external chest appearance, no thrill, S1S2, no abnormal sounds. peripheral pulse presents and normal (2+).
Respiratory: Normal external chest appearance and expansion, no fremitus, and normal pulmonary sound in all pulmonary areas, no adventitious sounds.
abdomen, soft, globules, normal bowel sound in all quadrants, no pain to light, or deep palpation. kidneys no palpable. CVA no painful to percussion.
GU: external genital normal, speculum exam normal
Pelvic examination, with no pian and uterus normal size and consistency. Speculum: vagina with normal color and normal vercix, no lesion noticed and no discharge.
Bimanual examination: Uteros anteversion and no mass noticed , various not palpable and uterus with the normal size and no pain detected during the exam.
Musculoskeletal: Pt refused.
Skin, nails, and hair intact.
Neurology: pt refused.
Cranial nerves: I normal; II normal; III, IV, VI, normal; V normal; VII normal; VIII Normal; IX normal; X normal. XI normal, XII normal.
Diagnostic IUD insertion
,
Labs:
CBC and BMP normals.
IUD inserted with no complications.
Vaginal ultrasound.( normal)
Pap smear ( done )

 

 

the one that said: soap note.

Age: 29 years
Race: Hispanic
Gender: Female
Insurance: No insurance
Referral: No referral
Clinical Information
Time with Patient: 45 minutes
Consult with Preceptor: 15 minutes
Type of Decision-Making: Low complexity
Student Participation: Primary (>50%)
Reason for Visit: Episodic
Chief Complaint: I have a lesion in my vagina
Encounter #: 1
Type of HP: Problem Focused
Social Problems Addressed: Income/Economic
Sanitation/Hygiene
Safety
Issues w/Community Resources
Social Contact/Isolation
Prevention
Education/Language
Nutrition/Exercise
Procedures/Skills (Observed/Assisted/Performed)
General Skills – Pelvic exam (Asst)
General Skills – STD & HIV screening/counseling (Asst)
ICD-10 Diagnosis Codes
#1 – A60.00 – HERPESVIRAL INFECTION OF UROGENITAL SYSTEM, UNSPECIFIED
CPT Billing Codes
#1 – 99203 – OFFICE/OP VISIT, NEW PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 30-44 MIN
#2 – 2010F – VITAL SIGNS DOCUMENTED AND REVIEWED
#3 – 99071 – PATIENT EDUCATION MATERIALS PROVIDED BY PHYSICIAN/OTHER PROFESSIONAL
#4 – 87623 – INFECTIOUS AGENT, NUCLEIC ACID (DNA/RNA); HUMAN PAPILLOMAVIRUS LOW-RISK TYPES
#5 – 1119F – INITIAL EVALUATION FOR CONDITION
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 – Antiviral agents		 Adherence Issues with Medications:
Disappearance of symptoms
Knowledge deficit
Other Questions About This Case
Nutritional Status: Good
Smoking Assessment: Non-smoker
Trimester:
Patient’s primary language: Spanish
Ethnicity: Spanic/Latin
History of present illness (HPI): 29 y/o female who comes because she ahs a lesion in her vagina
Other current meds/herbals/vitamins: no
TIme spent performing family assessment: 5 min
Blind :
Deaf:
Screen for drugs: Yes
Screen for alcohol: Yes
Homeless:
Religious practices affecting care:
Immunizations up to date: Yes
Patient is non-ambulatory:
Patient is ambulatory:
Antepartum new:
Peri/postmenopausal visit:
Breastfeeding eval and counseling:
Early postpartum visit < 1 week:
Home birth:
Newborn assessment:
Clinical Notes
CC:” I have itchy and vesicular in my private parts”
HPI: 29 y/o Hispanic female who comes to the clinic today because of a painful, itchy rash in her vagina. Patient refers that the initial symptoms was a painful sensation with skin lesions and 2day ago the vesicular lesions appear in the same site and now she has itchy and the pain is table with minimal relive with Tylenol or ibuprofen. Patient states no rash in other body part, denies any fever, or cough. Patient denies previous treatment for recently or old STD. Denies weight change.
PMH: healthy.
Vaccination up to date.
NKA
Medication: Tylenol 500 mg as needed for the pain
Ibuprofen 200 mg 400 mg q 6h as needed for pain.
Vital signs:
BP: 110/67, HR: 67, RR: 18, Temp: 98.0 pain: 7/10 now.
ROS: General: The patient denies any memory problems, no headache, denied visual, or hearing loss, or reading glass use, denies tingling, or numbness, no muscle weakness, or walking problems. Pt states no walking problems. Denies dizziness or vomiting.
HEENT: Pt Denies any ear, eyes, or neck pain. No visual or hearing changes. Pt states no nasal secretion denies nose bleeding, or tooth pain, refers no swallowing, or chewing problems. She states good smell and sense of taste. Pt denies Thyroid problems.
Cardiovascular: Pt denies, and denies chest pain, shortness of breath, or leg pain. No skin color change. No edema, no cyanosis. Peripheral pulse presents and 2+.
Respiratory: Pt denies shortness of breath, or cough, or chest pain. No sputum production.
GI: Pt denies any retrosternal pain, no nausea or vomiting, no diarrhea, no blood in the stool, denies constipation and state regular daily BM.
GU: Patient denies dysuria during or Nycturia and even he denies blood in urine. Pt states no vaginal discharge and states regular and normal bleeding during the menstrual periods but states vaginal vesicular and itchy.
Musculoskeletal: No painful walking and no muscle weakness. Spine with no problems.
Skin: Patient refers painful, itchy, vesicular rash in the upper back.
Physical exam:
General: Pt came with normal walking and appearance, well-groomed and dressed, alert, and oriented to time, person, place and situation, normal speech.
HEENT: head normal, normal hair implantation and distribution, for the age, ear normal implantation with no pain at palpation, no drainage, normal tympanic membrane. Nasal mucosae red and congestive and clear discharge notice coming from the nares, no pain on pressure over the frontal and maxillary sinus. Normal eyes, no nystagmus, PERRLA, normal eyes movements in all quadrants. Neck flexible, no mass, no nodules, thyroid no visible not palpable.
Cardiovascular: Normal external chest appearance, no thrill, S1S2, no abnormal sounds. peripheral pulse 2+
Respiratory: Normal external chest appearance and expansion, no fremitus, and normal pulmonary sound in all pulmonary areas.
abdomen, soft, flat, normal bowel sound in all quadrants, no pain to light, or deep palpation. kidneys no palpable. CVA no painful to percussion.
GU: No discharge but external genital and anus covered by vesicular with clear liquid and redness.
Musculoskeletal: Normal upper and lower extremities, respond to commands and against resistance spine normal, normal articulation. Normal gait, no ataxia. No Painful movements to walk and no inflammation noticed. Spine normal, no scoliosis.
Skin: vesicular lesions in the introit and external genital and anus. Nails intact, and normal hair distribution.
Neurology: Patient with a normal gait, alert and oriented to person, time, place and situation, normal speech, and written. superficial and deep tendon reflexes normal. Normal light and deep sensation, hyperesthesia in the left upper side of the back. Stereognosis, graphesthesia normal. No Babinski. No ataxia, normal gait.
Cranial nerves: I normal; II (tested with the reading glasses) normal; III, IV, VI, normal; V normal; VII normal; VIII Normal; IX normal; X normal. XI normal, XII normal.
Diagnostic: Herpes simple genital
Plan: Ibuprofen 200mg 2tab as needed for pain.
Acyclovir 400 q 4h x10 days.
Acyclovir cream every 3 hours x 7 days.
9 days ago
and that one is the case log for the first SOAP note.
9 days ago

This one is the 2nd case log for the second Soap note;

Age: 30 years
Race: White, Non Hispanic
Gender: Female
Insurance: No insurance
Referral: No referral
Clinical Information
Time with Patient: 45 minutes
Consult with Preceptor: 15 minutes
Type of Decision-Making: Low complexity
Student Participation: Less than shared
Reason for Visit: Episodic
Chief Complaint: I came for the labs review and for a IUD insertion
Encounter #: 1
Type of HP: Problem Focused
Social Problems Addressed: Sanitation/Hygiene
Safety
Issues w/Community Resources
Emotional
Sexuality
Prevention
Nutrition/Exercise
Procedures/Skills (Observed/Assisted/Performed)
General Skills – Breast exam (Asst)
General Skills – Immunizations (Asst)
General Skills – Interpret lab studies (Asst)
General Skills – Pap smear (Asst)
General Skills – STD & HIV screening/counseling (Asst)
ICD-10 Diagnosis Codes
#1 – Z30.8 – ENCOUNTER FOR OTHER CONTRACEPTIVE MANAGEMENT
#2 – Z01.419 – ENCNTR FOR GYN EXAM (GENERAL) (ROUTINE) W/O ABN FINDINGS
CPT Billing Codes
#1 – 99203 – OFFICE/OP VISIT, NEW PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 30-44 MIN
#2 – 2010F – VITAL SIGNS DOCUMENTED AND REVIEWED
#3 – 99071 – PATIENT EDUCATION MATERIALS PROVIDED BY PHYSICIAN/OTHER PROFESSIONAL
#4 – 58300 – INSERTION, INTRAUTERINE DEVICE
Birth & Delivery
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic – NSAIDS		 Adherence Issues with Medications:
Other Questions About This Case
Nutritional Status: Good
Smoking Assessment: Former Smoker
Trimester:
Patient’s primary language: Spanish
Ethnicity: Spanic/Latin
History of present illness (HPI): #0 y/o female who comes today for a IUD insertion
Other current meds/herbals/vitamins: multivitamins
TIme spent performing family assessment: 5
Blind :
Deaf:
Screen for drugs: Yes
Screen for alcohol: Yes
Homeless:
Religious practices affecting care:
Immunizations up to date: Yes
Patient is non-ambulatory:
Patient is ambulatory: Yes
Antepartum new:
Peri/postmenopausal visit:
Breastfeeding eval and counseling:
Early postpartum visit < 1 week:
Home birth:
Newborn assessment:
Clinical Notes
CC: I came for the lab’s review and for an IUD insertion
HPI: 30 y/o female who comes today to check the labs for the IUD insertion as birth control.. G3T2P2A1L2.
Medication: levothyroxine 125mch daily
NKA
Viatls BP 120/60 ( manual) HR: 67, RR 19, temp: 97.5

Review of systems:
ROS: General: The patient denies any memory problems, no headache. denied visual, or hearing loss, or reading glass use, denies tingling, or numbness, no muscle weakness, pt denies walking problems and No mood changes. No psychiatric problems.
HEENT: Pt Denies any ear, or neck pain. Pr denies visual problems. Pt denies nasal, denies nose bleeding, or tooth pain. Patient denies sore throat but states good smell and sense of taste. Pt denies Thyroid problems.
Cardiovascular: Pt denies hypertension, and denies chest pain, shortness of breath, palpitations, no leg pain. No skin color change. No edema, no cyanosis.
Respiratory: Pt denies shortness of breath, or fatigue, no cough, denies chest pain. No sputum production.
GI: Pt denies any retrosternal pain, no nausea or vomiting, no diarrhea, no blood in the stool, denies constipation and states regular daily BM.
GU: The patient denies dysuria during or Nycturia and even he denies blood in the urine. Ptdenies heavy vaginal bleeding during her regular periods.

Musculoskeletal: No pain or difficulty walking and no muscle weakness. Spine with no problems.
Physical exam:
General. Pt came walking normal, and appearance, well-groomed, alert, and oriented to person, time, place and situation, normal speech. No distress notice, normal mood.
HEENT: head normal, normal hair implantation and distribution, for the age, ear normal implantation with no pain at palpation, no drainage, normal tympanic membrane. Nasal mucosae pink and moist, no pain on pressure over the frontal and maxillary sinus. Red eyes, no secretion noted, no nystagmus, PERRLA, normal eye movements in all quadrants. Neck flexible, no mass, no nodules, thyroid no visible not palpable.
Cardiovascular: Normal external chest appearance, no thrill, S1S2, no abnormal sounds. peripheral pulse presents and normal (2+).
Respiratory: Normal external chest appearance and expansion, no fremitus, and normal pulmonary sound in all pulmonary areas, no adventitious sounds.
abdomen, soft, globules, normal bowel sound in all quadrants, no pain to light, or deep palpation. kidneys no palpable. CVA no painful to percussion.
GU: external genital normal, speculum exam normal
Pelvic examination, with no pian and uterus normal size and consistency. Speculum: vagina with normal color and normal vercix, no lesion noticed and no discharge.
Bimanual examination: Uteros anteversion and no mass noticed , various not palpable and uterus with the normal size and no pain detected during the exam.
Musculoskeletal: Pt refused.
Skin, nails, and hair intact.
Neurology: pt refused.
Cranial nerves: I normal; II normal; III, IV, VI, normal; V normal; VII normal; VIII Normal; IX normal; X normal. XI normal, XII normal.
Diagnostic IUD insertion
,
Labs:
CBC and BMP normals.
IUD inserted with no complications.
Vaginal ultrasound.( normal)

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