SOAP NOTE OB 3 SUBACUTE VAGINITIS
osmel32
viewdetail-2844-20220125-001.doc<table border="0" width="100%" cellpadding="0" cellspacing="0"> <tr> <td bgcolor="#000000" style="padding-left:2px; padding-right:10px; padding-top:2px; padding-bottom:2px"> <p><font color="#FFFFFF" size="2"> <b>Miami Regional University </b>(Acct #3111)</font></td> </tr> </table> <font size="2"> </font> <table border="0" width="100%" cellpadding="0" cellspacing="0" bgcolor="#C0C0C0"> <tr> <td width="50%"><b><font size="2"> Case ID #: 2844-20220125-001</b></font><font size="2"> (Status: Pending) </font></td> <td width="50%"> <p align="right"><b><font size="2">Date of Service: 1/25/2022 </font></b><font size="2"></b></font></font></font></td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td WIDTH="100%" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> <p align="center"><font color="#FFFFFF" size="2"><b>Student Information - Santiesteban Molina, Osmel</b></font></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> <p align="right"><font size="2"><b>Semester:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF"> <font size="2"> Spring </font> </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> <font size="2"><b>Course:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF"> <font size="2"> MSN6050C Advanced Practice Women Health </font> </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> <b><font size="2">Preceptor: </font></b></td> <td WIDTH="50%" bgcolor="#FFFFFF"> <font size="2"> TREJO, RODOLFO </font> </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18" valign="top"> <b><font size="2">Clinical Site</font></b><font size="2"><b>:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> <font size="2"> Neighborhood Family Doctor.Atlantis </font> </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18" valign="top"> <b><font size="2"> Setting Type</font></b><font size="2"><b>:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> <font size="2"> Underserved area/population </font> </td> </tr> <tr> <td WIDTH="100%" bgcolor="#000000" align="right" colspan="2" style="border-style: solid; border-width: 2px"> <p align="center"><font color="#FFFFFF" size="2"><b>Patient Demographics</b></font></td> </tr> <tr> <td bgcolor="#FFFFFF"> <p align="right"><font size="2"><b> Age:</b></font></td> <td bgcolor="#FFFFFF"> <font size="2"> 24 years </font> </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF"> <p align="right"><b><font size="2">Race</font></b><font size="2"><b>:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF"><font size="2"> Hispanic </font></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF"> <p align="right"><b><font size="2">Gender</font></b><font size="2"><b>:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF"><font size="2"> Female </font></td> </tr> <tr> <td bgcolor="#FFFFFF"> <p align="right"><b><font size="2">Insurance</font></b><font size="2"><b>:</b></font></td> <td bgcolor="#FFFFFF"> <font size="2"> Private insurance </font></td> </tr> <tr> <td bgcolor="#FFFFFF"> <p align="right"><b><font size="2">Referral</font></b><font size="2"><b>:</b></font></td> <td bgcolor="#FFFFFF"> <font size="2"> No referral </font></td> </tr> <tr> <td valign="top" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> <p align="center"><font color="#FFFFFF" size="2"><b>Clinical Information</b></font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <p align="right"><font size="2"><b> Time with Patient:</b></font></td> <td bgcolor="#FFFFFF"> <font size="2"> 15 minutes</font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <p align="right"><font size="2"><b> Consult with Preceptor:</b></font></td> <td bgcolor="#FFFFFF"> <font size="2"> 5 minutes</font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <b><font size="2">Type of Decision-Making:</font></b></td> <td bgcolor="#FFFFFF"> <font size="2"> Straightforward </font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <b><font size="2">Reason for Visit:</font></b></td> <td bgcolor="#FFFFFF"> <font size="2"> Follow-up (Consult) </font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <b><font size="2"> Chief Complaint:</font></b></td> <td bgcolor="#FFFFFF"> <font size="2">" I have itching my private parts" </font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <b><font size="2">Type of HP:</font></b></td> <td bgcolor="#FFFFFF"> <font size="2"> Problem Focused </font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right" valign="top"> <b><font size="2">Social Problems Addressed:</font></b></td> <td bgcolor="#FFFFFF"> <font size="2"> Safety<br>Emotional<br>Sexuality<br> </font></font></td> </tr> </table> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td width="100%" bgcolor="#000000" align="center" colspan="2" style="border-style: solid; border-width: 2px"> <font color="#FFFFFF" size="2"><b>Procedures/Skills (Observed/Assisted/Performed)</b></font></td> </tr> <tr> <td width="100%" bgcolor="#FFFFFF" align="left" colspan="2"><font size="2"> </font></td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td width="100%" bgcolor="#000000" align="center" colspan="2" style="border-style: solid; border-width: 2px"> <font color="#FFFFFF" size="2"><b>ICD-10 Diagnosis Codes</b></font></td> </tr> <tr> <td width="10%" bgcolor="#FFFFFF" align="right" valign="top"> <b><font size="2">#1 -</font></b><font size="2"> </font> </td> <td width="90%" bgcolor="#FFFFFF" align="left"> <font size="2"> N76.1 - SUBACUTE AND CHRONIC VAGINITIS </font> </td> </tr> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> <p align="center"><font color="#FFFFFF" size="2"><b>CPT Billing Codes</b></font></td> </tr> <tr> <td width="10%" bgcolor="#FFFFFF" align="right" valign="top"> <b><font size="2">#1 -</font></b><font size="2"> </font> </td> <td width="90%" bgcolor="#FFFFFF" align="left"> <font size="2"> 99202 - OFFICE/OP VISIT, NEW PT, MEDICALLY APPROPRIATE HX/EXAM; STRTFWD MED DECISION; 15-29 MIN </font> </td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" cellpadding="1"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px" bordercolor="#99CCFF"> <p align="center"><b><font size="2" color="#FFFFFF">Birth & Delivery</font></b></td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" cellpadding="1"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px" bordercolor="#99CCFF"> <p align="center"><b><font size="2" color="#FFFFFF">Medications</font></b></td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> <p><b><font size="2"># OTC Drugs taken regularly:</font></b></td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> <font size="2"> 0</font></td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> <b><font size="2"># Prescriptions currently prescribed:</font></b></td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> <font size="2"> 2</font></td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> <b><font size="2"># New/Refilled Prescriptions This Visit:</font></b></td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> <font size="2"> 1</font></td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> <u> <b><font size="2">Types of New/Refilled Prescriptions This Visit:</font></b></u><font size="2"><BR> Gynecology - Vaginal anti-infectives<BR> </font></td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> <u> <b><font size="2">Adherence Issues with Medications:</font></b></u><font size="2"><BR> </font></td> </tr> </table> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" bordercolor="#99CCFF" style="border-style: solid; border-width: 2px"> <p align="center"><b><font size="2" color="#FFFFFF">Other Questions About This Case</font></b></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> <b><font size="2">Patient's Primary Language:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> <font size="2"> Spanish </font> </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> <b><font size="2">Smoking Assessment:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> <font size="2"> Never </font> </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> <b><font size="2">Advanced Directive:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> <font size="2"> No </font> </td> </tr> <tr><td bgcolor='#FFFFFF' valign = 'top' width='50%'><p align='right'><font size='2'><b>Packs per day:</b></font></td><td bgcolor='#FFFFFF'><font size='2'>0</font></td></tr> </table> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF"> <tr> <td width="100%" bgcolor="#000000" align="left" valign="top" colspan="2" bordercolor="#99CCFF" style="border-style: solid; border-width: 2px"> <p align="center"><font color="#FFFFFF" size="2"><b>Clinical Notes</b></font></td> </tr> <tr> <td width="100%" bgcolor="#FFFFFF" align="left" valign="top" colspan="2"> <font size="2"> </font> </td> </tr> </table>
