SOAP note- PCOS

ID:

Client’s Initials*:MR Age: 34 Race: hispanic Gender: female Date of Birth:

Marital Status: single

*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect patient confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.

Subjective:

CC: “my periods are irregular and painful”

HPI:

In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.

Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.

Past Medical History:

· Medical problem list

· Preventative care: (if applicable to the case - Paps, mammography, colonoscopy, dates of last visits, etc.)

· Surgeries:

· Hospitalizations:

· LMP, pregnancy status, menopause, etc. for women

Allergies:

Food, drug, environmental

Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use

Family History:

Social History:

-Sexual history and contraception/protection (as applies to the case)

-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here - what is pertinent and necessary for safe and holistic care)

ROS (write out by system): Comprehensive ( >10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed - review and document the pertinent systems. Do not include diagnoses - those belong in PMH. The below categories are per CMS guidelines.

Constitutional:

Cardiovascular:

Pulmonary:

Gastrointestinal:

Genitourinary:

Integumentary & breast:

Neurological:

Psychiatric:

Endocrine:

Allergic/Immunologic:

Objective

Vital Signs: HR BP Temp RR SpO2 Pain

Height Weight BMI

Labs, radiology or other pertinent studies: be sure to include the date of labs - might be POC tests from today

Physical Exam (write out by system):

Start with a general survey:

Assessment

(you will often have more than one diagnosis/problem, but do the differential on the main problem)

Differentials (with a brief rationale for each include ICD-10): WITH REFERENCES

1- Polycystic ovarian syndrome

2- Hypothyroidism

3- Cushing’s Syndrome

Inmunization Encounter for immunization

ICD Z23

It is recommended that adults receive a single dose of Tdap and followed by Td or a Tdap

booster every 10 years (Centers for Disease control and Prevention [CDC], 2020). Patient

is updated with immunizations except for Tdap.

4- Encounter for immunization

5- ICD Z23

6- It is recommended that adults receive a single dose of Tdap and followed by Td or a Tdap

7- booster every 10 years (Centers for Disease control and Prevention [CDC], 2020). Patient

8- is updated with immunizations except for Tdap.

3.

Diagnosis

Plan (4 pronged-plan for each problem on the problem list)

Diagnostics:

Treatment: medication needs reference

Education

Follow Up:

List plan under each Diagnosis.

Example

1: Hypertension (I10)

A: Lisinopril/HCT 20/12.5 Daily #90, refills 3

B: BMP in 6 months

C: Recheck BP in 2 Weeks

D: Low Sodium Diet and lifestyle modifications discussed

2: Morbid Obesity BMI XX.X (E66.01)

A: Goal of 5% weight reduction in 3 months

B: Increase exercise by walking 30 minutes each day

C: Portion Size Education

3: T2 Diabetes with diabetic neuropathy (E11.21)

A: Repeat A1C in 3 months

B. Increase Metformin to 1000mg BID #180, refills: 3

C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)

D: Daily blood glucose check in the am and when sick

E. Return to clinic in 3-4 months to reassess