Soap note

Student Information Semester: Spring Course: MSN6050C Advanced Practice Women Health Preceptor: TREJO, RODOLFO Clinical Site: NEIGHBORHOOD FAMILY PRACTICE Setting Type: Rural visit - Patient Demographics Age: 21 years Race: Hispanic Gender: Female Insurance: Medicare Referral: No referral Clinical Information Time with Patient: 28 minutes Consult with Preceptor: 15 minutes Type of Decision-Making: Moderate complexity Reason for Visit: Episodic Chief Complaint: I have a lesion on my genitalia Type of HP: Expanded Problem Focused Social Problems Addressed: Sanitation/Hygiene Safety Sexuality Prevention   Procedures/Skills (Observed/Assisted/Performed) Physical Assessment - Physical Assessment (Perf) General Skills - Vaginal Exam (Perf) General Skills - Vital Signs (Perf) ICD-10 Diagnosis Codes #1 -  A60.04 - HERPESVIRAL VULVOVAGINITIS CPT Billing Codes #1 -  99204 - OFFICE/OP VISIT, NEW PT, MEDICALLY APPROPRIATE HX/EXAM; MODERATE LEVEL MED DECISION; 45-59 MIN Birth & Delivery Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 0 # New/Refilled Prescriptions This Visit: 2 Types of New/Refilled Prescriptions This Visit: Analgesic/Antipyretic - NSAIDS Infectious Diseases - Antiviral agents   Adherence Issues with Medications:   Other Questions About This Case Patient's Primary Language: Spanish Smoking Assessment: Never Advanced Directive: No Packs per day: