MR week 9 soap

SOAP Note _______

NU___:_________

Herzing University

Name:_________________________

Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA 3398-20251020-001   Comprehensive assessment

CC:

“I’m here for my annual well-woman exam.”

HPI:

· Onset (O): “Routine annual visit; no acute complaints.

· Location (L): General gynecologic and preventive examination.

· Duration (D): N/A (preventive visit).

· Characteristics (C): Reports feeling healthy overall; no abnormal uterine bleeding, pelvic pain, vaginal itching, discharge, or odor.

· Aggravating/Associated Factors (A): None reported.

· Relieving Factors (R): Regular exercise, balanced diet, and self-care practices.

· Treatment Tried (T): None needed; preventive maintenance.

· Summary (S): 32-year-old African American female presents for an annual well-woman exam. Denies current symptoms or concerns. Reports regular menstrual cycles (28–30 days, lasting ~5 days, moderate flow, mild cramps). Performs monthly breast self-awareness.

PMH:

No chronic illnesses or prior surgeries.

OBGYN History:

· G2P2 (two full-term vaginal deliveries).

· LMP: 10/10/2025.

· Last Pap smear: 2022 (normal).

· No history of abnormal results or gynecologic disease.

ALLERGIES

No known drug allergies (NKDA).

MEDICATIONS

None.

SH

Non-smoker; drinks alcohol socially; denies drug use. Exercises 3×/week (walking/jogging). Balanced diet. Employed full-time; uses relaxation techniques for moderate stress. Stable housing and relationship.

FH

· Mother: Hypertension.

· Father: Healthy.

· No family history of breast, cervical, ovarian, or colon cancer.

HEALTH PROMOTION & MAINTENANCE

· Mammogram: Not indicated (age <40).

· Pap: Collected today; last normal in 2022.

· Immunizations: Up to date.

· STI prevention: Uses condoms consistently.

· Exercise: Encouraged ≥150 minutes/week.

· Nutrition: Adequate calcium and vitamin D intake.

· Dental/Eye exams: Annually.

ROS

(put N/A in sections not completed day of exam)

Constitutional

Head

No headache.

Eyes

No vision changes.

Ears, Nose, Mouth, Throat

No pain, congestion, or discharge.

Neck

No swelling or pain.

Cardiovascular/Peripheral Vascular

Denies chest pain or palpitations.

Respiratory

Denies cough, dyspnea, or wheezing.

Breast

No pain, nipple discharge, or lumps.

Gastrointestinal

Normal appetite; no nausea, vomiting, or constipation

Genitourinary

No dysuria, urgency, or frequency.

Pelvis

No pelvic pain or discharge.

Musculoskeletal

No pain or swelling.

Integumentary

No rashes or lesions.

Neurological

Alert, oriented; no dizziness.

Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)

Normal mood; denies anxiety or depression.

Endocrine

No heat/cold intolerance, polyuria, or polydipsia.

Hematologic/Lymphatic

No bruising or adenopathy”.

Allergic/Immunologic

NKDA.

Other

N/A

O: OBJECTIVE DATA

VITALS:

“HR: 72 bpm

RR: 16/min

BP: 118/76 mmHg

Temp: 98.2°F (36.8°C)

SpO2%: 99%

Ht: 165 cm

Wt: 64 kg

BMI: 23.5 kg/m²

Age: 32 years

LMP: 10/10/2025

PAIN: 0/10

PHYSICAL EXAM

General Appearance

Well-developed, well-nourished, alert, cooperative, in no acute distress.

Head

Normocephalic, atraumatic.

Eyes

PERRLA, conjunctiva clear.

ENT, Mouth

Moist mucosa, no lesions.

Neck

Supple, no thyromegaly, no lymphadenopathy.

Cardiovascular/Peripheral Vascular

Regular rate and rhythm, no murmurs or edema.

Respiratory

Lungs clear bilaterally.

Breast

No tenderness, masses, or discharge.

Gastrointestinal

Soft, non-tender, no hepatosplenomegaly.

Genitourinary Female

· External Exam

Normal

· Internal Exam

Deferred

Pelvic

Normal vulva and cervix; no discharge or lesions. Uterus normal size and mobile. Adnexa non-palpable. Pap obtained.

Musculoskeletal

Full range of motion, no tenderness.

Integumentary

Skin warm, dry, intact.

Neurological

Alert and oriented ×3; no deficits.

Psychiatric

Mood appropriate, cooperative.

Endocrine

No thyromegaly or tremors.

Hematologic/Lymphatic

No lymphadenopathy or pallor.”

A: ASSESSMENT AND DIAGNOSIS

“DIAGNOSIS

ICD-10 CODES

PRIORITIZE DIAGNOSIS

1. Routine Well-Woman Exam

Z01.419

2. Cervical Cancer Screening

Z12.4

3. Contraceptive Counseling

Z30.09

VISIT CODES

CPT BILLING CODES

99395

DIAGNOSTICS

POC TESTING

None performed today.

TESTS REVIEWED

None; recommended follow-up labs

P: PLAN

ACTIONS

1.

Diagnosis: Encounter for gynecological examination (routine, without abnormal findings)

Diagnostics Ordered

· Pap smear with HPV co-testing sent to lab.

· Routine urinalysis as baseline preventive screen.

Therapeutic

· Continue healthy lifestyle; no medication needed.

Education

· Reviewed importance of annual preventive care, safe sexual practices, adequate hydration, and balanced diet.

· Encourage regular aerobic and weight-bearing exercise ≥150 min/week.

· Stress management via relaxation, yoga, or mindfulness.

Collaboration

· None required; continue routine primary care follow-up.

2.

Diagnosis: Cervical Cancer Screening

Diagnostics Ordered

· Pap cytology + HPV co-test sent to lab.

· Follow-up based on results (3 years if normal, 1 year if abnormal).

Therapeutic

· Routine prevention; continue healthy habits.

Education

· Explained cervical cancer prevention, HPV link, and importance of consistent screening.

Consultation/Collaboration

· Refer to gynecology if abnormal results or colposcopy indicated.

3.

Diagnosis: Contraceptive Counseling

Diagnostics Ordered: None

Therapeutic:

· Continue condom use for contraception and STI prevention.

Education:

· Reviewed contraceptive options (OCPs, IUDs, implants).

· Reinforced dual protection (condom + method if pregnancy prevention desired).

Consultation/Collaboration:

· Offer referral to family planning services if patient opts for alternative contraception in future.

PREVENTITIVE

· Maintain BMI <25 through regular aerobic activity ≥150 min/week.

· Continue healthy diet with fruits, vegetables, lean protein.

· Annual dental and eye exams.

· Immunizations verified as up to date.

· Encourage stress management, mindfulness, or relaxation activities.

FOLLOW UP

· Annually for well-woman exam or sooner if new symptoms arise.

· Pap/HPV Results”: Will contact patient with results and discuss next screening interval.