Soap note Unspecified menopausal and perimenopausal

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Semester:

Spring

Course:

MSN6050C Advanced Practice Women Health

Preceptor: 

TREJO, RODOLFO 

Clinical Site:

NEIGHBORHOOD FAMILY PRACTICE

Setting Type:

Patient Demographics

Age:

55 years

Race:

Hispanic

Gender:

Female

Insurance:

Medicare

Referral:

No referral

Clinical Information

Time with Patient:

30 minutes

Consult with Preceptor:

15 minutes

Type of Decision-Making:

Low complexity

Reason for Visit:

Episodic

Chief Complaint:

No period for 4 months 

Type of HP:

Problem Focused

Social Problems Addressed:

Sanitation/Hygiene Safety Education/Language Nutrition/Exercise  

Procedures/Skills (Observed/Assisted/Performed)

Physical Assessment - Physical Assessment (Perf) General Skills - Vital Signs (Perf)

ICD-10 Diagnosis Codes

#1 - 

N95.9 - UNSPECIFIED MENOPAUSAL AND PERIMENOPAUSAL DISORDER

#2 - 

E08.9 - DIABETES DUE TO UNDERLYING CONDITION W/O COMPLICATIONS

#3 - 

I10 - ESSENTIAL (PRIMARY) HYPERTENSION

CPT Billing Codes

#1 - 

99202 - OFFICE/OP VISIT, NEW PT, MEDICALLY APPROPRIATE HX/EXAM; STRTFWD MED DECISION; 15-29 MIN

Birth & Delivery

Medications

# OTC Drugs taken regularly:

0

# Prescriptions currently prescribed:

2

# New/Refilled Prescriptions This Visit:

1

Types of New/Refilled Prescriptions This Visit: Endocrinology - Minerals/vitamins  

Adherence Issues with Medications:  

Other Questions About This Case

Patient's Primary Language:

Spanish

Smoking Assessment:

Never

Advanced Directive:

No