Create 25 women’s Health Soap notes.
Create 25 women’s Health Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new grad perspective. Include a variety of preventive visits,acute, chronic, and wellness disorders pertaining only to this population.
Documentation Requirements
Must Include
Patient Demographics Section:
Age
Race
Gender
Clinical Information Section:
Time with Patient
o Reason for visit
o Chief Complaint
o Social Problems Addressed
Medications Section:
o # OTC Medications taken regularly
o # Prescriptions currently prescribed
o # New/Refilled Prescriptions This Visit
ICD 10 Codes Category:
o Include for each diagnosis addressed at the visit
CPT Billing Codes Category:
o Include Evaluation and management code
o Provider procedure codes (pap smear, destruction of lesion, sutures, etc.)
Other Questions About This Case Category:
o Age Range
o Patient type
o HPI
o Patients Primary Language
o Did you chart on the patient record?
o Discussed Management with the Preceptoro Handled Visit Independently
o Preceptor Present During Visit
Clinical Notes Category :
PLEASE follow this format
ChiefComplaint: “***”
DIAGNOSIS:
PLAN:
Diagnostics:
Therapeutics:
Education:
Consultation/Collaboration:
Solution Preview
Soap Notes for Women’s Problems
Genital Herpes
Patient Demographics
- Name: Mary Clark
- Age: 42
- Race: Caucasian White
- Gender: Female
- Primary language: English
Clinical Information
Chief Complaint:
The patient presented to the centre on 15th December, 2018 with lower abdominal pains.
History of present illness and analysis of symptoms
Patient reports pains in the lower abdomen, prolonged menstrual bleeding
Social problems
The has two children 10 and 5, divorced and lives with her children and her sister in an apartment.; alleged rape three months ago on her way from work.
(4,915 words)