Submit 1 mini-SOAP note on a patient that you saw in GYN clinic
Submit 1 mini-SOAP note on a patient that you saw in GYN clinic this week. Submit here as a Word Document. See example template below.
Patient initial (one initial only), 64 yrs old, and female must be HIPAA compliant
Chief Complaint – status post 11 years ago partial hysterectomy and is NOW having urinary incontinence and pressure in the pelvic area.
History of Present Illness (HPI) on September 2011 she had a partial hysterectomy due to fibroids in the uterus in New York. She also had a right mastectomy and lymph node removal on October 2021. She refused to take Tamoxifen for breast cancer treatment (this should be in a paragraph form)
Remember to use OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment.
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
Family Hx: (please do not put No information given) Mother hypertension Father has arthritis Diabetes Chronic kidney disease, etc.
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Physical findings listed by body systems, not paragraph form
Assessment (Diagnosis/ICD10 Code)
Include all diagnoses that apply for this visit
Dx Plan (lab, x-ray)
Tx Plan: (meds)
Pt. Education, including specific medication teaching points
Health maintenance (including when screenings, immunizations, etc., are next due):