Episodic SOAP Note Template Example

Episodic SOAP Note Template Example

Episodic Focused SOAP Note Example

Patient Information:

TMF, 23, AAF

S.

CC “I noticed that I have an odor down there”

HPI: Patient presents to office for a follow up from her appt on 02/6/23 well woman gynecological visit in which her pap smear resulted: ABNORMAL ASCUS, HPV + but neg. for 16,18,45. Patient is scheduled on today’s date for a colposcopy. Patient also reports that for the past week she has been having a “fishy” vaginal odor. Denies discharge, pain or itching.

Current Medications:

EluRyng 0.12 mg-0.015 mg/24 hr vaginal ring

INSERT 1 RING VAGINALLY AS DIRECTED. Exchange ring every 4 weeks.

Ibuprofen 800mg Tablet

Use prn pain q 8 hours. Take with food.

azithromycin 500 mg tablet

TAKE 2 TABLETS BY MOUTH EVERY DAY FOR 1 DAY

Allergies: Patient denies allergies to food or medicine

PMHx: .

Atypical squamous cells of undetermined significance — Onset: 02/10/2020
Vaginitis — Onset: 08/17/2022 — ureaplasma and AV organisms
COVID-19 — Onset: 03/17/2020
HPV — Human papillomavirus test positive — Onset: 03/23/2018 — neg.16,18,45
Genital herpes simplex — Onset: 03/18/2018
Chlamydia –Onset: 03/18/2018

Soc & Substance Hx: Are you blind or do you have difficulty seeing?: No

Are you deaf or do you have serious difficulty hearing? No

Do you have difficulty concentrating, remembering or making decisions? No

Do you have difficulty walking or climbing stairs? No

Do you have difficulty dressing or bathing? No

Do you have difficulty doing errands alone? No

Diet and Exercise

What type of diet are you following? Regular

What is your exercise level? None

Other

Education: 12

History of inconsistent/no condom use: Yes

Marital status: Single

General stress level: Low

Education and Occupation

What is the highest grade or level of school you have completed or the highest degree you have received? High school graduate

Are you currently employed? Yes

What is your occupation? server/ leasing consultant

Substance Use

Do you or have you ever smoked tobacco? Never smoker

How much tobacco do you smoke? None

How many years have you smoked tobacco? NA

Do you or have you ever used any other forms of tobacco or nicotine? No

Do you or have you ever used e-cigarettes or vape? Never used electronic cigarettes

Do you or have you ever used smokeless tobacco? Never used smokeless tobacco

What was the date of your most recent tobacco screening? 02/06/2023

What is your level of alcohol consumption? Moderate (Notes: 1–3 times a week couple of drinks)

Do you use any illicit or recreational drugs? Yes

Which illicit or recreational drugs have you used? Cannabis

What is your level of caffeine consumption? Occasional (Notes: 1 8–12oz coffee daily)

Advance Directive

Do you have an advance directive? No

Is blood transfusion acceptable in an emergency? Yes

Marriage and Sexuality

What is your relationship status? Single

Are you sexually active? Yes

Public Health and Travel

Have you been to an area known to be high risk for COVID-19? No

In the 14 days before symptom onset, have you had close contact with a laboratory-confirmed COVID-19 while that case was ill? No

In the 14 days before symptom onset, have you had close contact with a person who is under investigation for COVID-19 while that person was ill? No

Lifestyle

Do you feel stressed (tense, restless, nervous, or anxious, or unable to sleep at night)? Not at all

Do you use your seat belt or car seat routinely? Yes

Home and Environment

Do you have smoke and carbon monoxide detectors in your home? Yes

Are there any guns present in your home? No

Do you use sunscreen routinely? Yes

Gender Identity and LGBTQ Identity

Gender identity: Identifies as Female

Assigned sex at birth: Female

Pronouns: she/her

Sexual orientation: Straight or heterosexual

Fam Hx:

No children

Father- No medical concerns or disabilities

Mother-No medical concerns or disabilities

Maternal Grandmother- DMII

Maternal Grandfather- Medical hx unk

Paternal Grandmother- Medical hx unk

Paternal Grandfather- Medical hx unk

Surgical Hx: Tonsillectomy (stated it was more than 15 years ago)

Mental Hx: No reports of depression, anxiety or SI

Violence Hx: States that neighborhood is safe, no guns in the home and feels safe in her relationship

Reproductive Hx:

Duration of Flow (days): 5.
LMP: Definite (Notes: 01/07/23–01/12/23).
Frequency of Cycle (Q days): 28.
Menses Monthly: N.
Flow: Moderate (Notes: uses regular pads changes 6 in 24 hours).
Age at First Child: 0.
Age at Menarche: 12.
Current Birth Control Method: Condoms (Notes: removed vaginal ring to give her body a break).
Abnormal Pap: Y (Notes: ASCUS HPV not typed).
Colonoscopy: (Notes: none).
Date of Last Pap Smear: 02/06/2023 (Notes: HPV + 16,18,45-).
Hormone Replacement Therapy: N.
Most Recent Bone Density: (Notes: none).
Most Recent Mammogram: (Notes: none).
Sexual Problems?: N.
Sexually Active?: Yes (Notes: last active date 02/15/2023).
STIs/STDs: Yes (Notes: herpes, had chlamydia years ago. HAs HPV).

Total (1) Full (0) Pre (0) AB.1 (0) AB.S (1) Ectopic (0) Living (0) Multiple (0)

Spontaneous abortion at 10 weeks age 15

ROS:

GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching. Breast-lumps, pain, discharge

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY: Denies burning on urination, frequency and urgency. Reports vaginal odor

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Constitiutional: Patient A&O x4. No deviations in gait. Clear and coherent speech. Answers questions appropriately. Makes good eye contact and is cooperative during assessment and exam. Dressed appropriately for weather and setting.

VS

Ht: 5 ft 3 in

Wt: 179 lbs

BMI: 31.7

BP: 118/80 sitting R arm

T: 98.5 F° oral

Cardiovascular: Normal rate and rhythm, No edema, No jugular vein distention

Respiratory: No SOB, Equal rise and fall of chest wall, cap refill ❤cc

Genitourinary: vaginal odor present,

Diagnosis:

A. Abnormal vaginal odor-

VIKTOR culture-probiotic

N89.8: Other specified noninflammatory disorders of vagina

Cervicovaginal cytology: Low grade squamous intraepithelial lesion

R87.612: Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)

PATHOLOGY REPORT-500918-P -

Note to Lab:

All pap done at LABCORPS,
2.6.23 ASCUS, HPV+ (not16,18,45)
11.24.21 HPV+ (neg., 16,18,45)
5.7.21 LGSIL QUEST labs
5.4.20 ASCUS, HPV
3.25.19 Normal
3.15.18 ASCUS. HPV+ neg. 16,18,45

Contraception care management

Z30.9: Encounter for contraceptive management, unspecified

Postoperative pain

G89.18: Other acute post procedural pain

Atypical squamous cells of undetermined significance on cervical Papanicolaou smear

R87.610: Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)

Procedure Documentation:

Colposcopy:

HPV+ (not 16,18,45) ASCUS X 2
Colposcopy procedure fully reviewed. Patient questions regarding procedure and diagnosis answered. Consent was signed. A speculum was placed into the vagina. The cervix and vagina were painted with acetic acid solution. The entire T zone was visualized with irregular borders.
Colposcopy revealed the following (see attached diagram):

Possible metaplasia or CIN 1–2
An ECC was not performed.
Silver nitrate stick & pressure was applied for hemostasis.
Patient tolerated procedure well.

Ibuprofen 800 mg. given with hot tea post

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Episodic SOAP Note Template Example