soapnote

· SUBJECTIVE DATA:

Patient Initials: _____    Age: _____      Gender: ___

Chief Complaint (CC):

History of Present Illness (HPI):

            Onset:

            Location:

            Duration:

     Characteristics:

            Aggravating factors:

            Relieving factors:

            Treatments/Therapies:

            Severity:

Medications:

           

Allergies:

 

Past Medical History (PMH):

             

Past Surgical History (PSH):

 

OB/GYN History:

            Menstrual History:

1. Age at menarche –

2. LMP-

3. Menstrual Pattern

a. Duration of flow-

b. Amount of flow-

c. Associated pain with menses-

d. Intermenstrual bleeding-

4. Menopause-

Contraception:

5. Current method and satisfaction-

6. Previous methods, complications, and reasons for discontinuation-

 

Cervical and vaginal cytology:

7. Most recent Pap –

8. History of abnormal pap smears-

Infections:

9. No history of STIs, vaginitis, or PID (if this is true for your patient)

Fertility/infertility:

      1.

Sexual History: (example)

10. Heterosexual, mutually monogamous relationship

11. No concerns with libido or orgasm. Has experienced intermittent dyspareunia x 1 month.

12. No history of sexual abuse or assault

13. Denies sexual intercourse in the last 7 days.

Obstetric history: (example)

14. G1P1001

15. Denies maternal, fetal, or neonatal complications

Personal/Social History:

 

            Health Maintenance:

(include things such as vitamin supplementation, diet, exercise routine, seatbelt use sunscreen use, firearms in the household, last pap and results, sigmoidoscopy/colonoscopy, bone densitometry, lipid analysis, glucose, or thyroid testing)

Immunizations History:

 

Significant Family History:

(don’t forget to list any family history of breast, ovarian, or uterine cancer)

Review of Symptoms:

General:

Skin:

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Hematologic:

Endocrine:

Allergic/Immunologic:

 

OBJECTIVE DATA:

Physical Exam:

Vital Signs

 

General:

HEENT:

Neck:

Chest:

Lungs:

Heart:

Peripheral Vascular:

Abdomen:

Genital/Rectal:

External Genitalia:

Vulva/Labia Majora:

Bartholin Gland:

Skenes:

Clitoris:

                        Urethra:

                        Bladder:

                        Vagina:

Cervix:

Uterus:

Adnexa:

Rectum:

Musculoskeletal:

Neurological:

Lymph Nodes:

Skin:

Lab/Diagnostic Tests and Results: (example)

16. Urine hCG- negative

17. Pap smear- results pending

18. Vaginal culture- pending

19. Urine STD panel- pending

20. Transvaginal US- pending

 

ASSESSMENT:

Differential Diagnosis (DDx):

1

2

3

 

 

  Final Diagnosis:

PLAN:

1.  

1.  

1.  

1. Referrals-

1. Further labwork or diagnostics needed??

1. F/U

1. Health Promotion:

1. Disease Prevention:

 

Reflection:

            References

Fantasia, H.C. (2017). Sexually transmitted infections. In K. D. Schuiling & F. E. Likis (Eds.), Women’s gynecologic health (3rd ed., pp. 465-511). Burlington, MA: Jones and Bartlett Publishers.

Murphy, P. A., Hewitt, C. M., & Belew, C. (2017). Contraception. In K. D. Schuiling & F. E. Likis (Eds.), Women’s gynecologic health (3rd ed., pp. 209-248). Burlington, MA: Jones and Bartlett Publishers.

O’Dell, K. K. (2017). Benign gynecologic conditions. In K. D. Schuiling & F. E. Likis (Eds.), Women’s gynecologic health (3rd ed., pp. 621-653). Burlington, MA: Jones and Bartlett Publishers.