soap note

 

14 years old female. Height 157cm Wt: 75kg. V/S: WNL. CBC, CMP, Lipid panel, Thyroid, HbA1c, HIV, STD test done. All results are normal except for STD:  

CT r RNA(TMA), Probe: Positive A  

This is Chlamydia test!!! 

Called pt and pt’s mother to visit the clinic for lab results explanation and treatment 

Pls write Chlamydia treatment including education, referral etc 

Do not forget the ICD 10 codes and cpt codes