Complete Note
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 0 Average: 0]
approximately 382 views since Marcus Tullius took some notes.
HISTORY:
[checkbox name="historian" value="provided by patient||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes or lack of knowledge|complete history unobtainable d/t language skills|"][textarea cols=70 rows=1]
Purpose of Visit/CC:
[checkbox name="purpose" value="annual screening|new problem|follow up on abnormal|"][textarea cols=70 rows=1]
Breast Sx:
[checkbox name="breast_cc" value="does not report||pain|swelling|lump|discharge|skin changes|abnormal imaging|family history|"][textarea cols=70 rows=1]
GI Sx:
[checkbox name="abdominal_cc" value="does not report||upper abd pain|lower abd pain|diarrhea|constipation|nausea/vomiting|"][textarea cols=70 rows=1]
Menstrual Sx:
[checkbox name="menstrual_cc" value="does not report||irregular menstruation|heavy menses|painful menses|spotting|missed|"][textarea cols=70 rows=1]
LMP: [textarea cols=10 rows=1 default="N/A"]
Urinary Sx:
[checkbox name="urinary_cc" value="does not report||burning|frequency|pain with urination|blood in urine|back pain||stress incontinence|urge incontinence|"][textarea cols=70 rows=1]
Vaginal Sx:
[checkbox name="vaginal_cc" value="does not report||clear discharge|thick discharge|yellow discharge|brown discharge||itching|skin lesions||painful intercourse|postcoital bleeding|prolapse||vaginal bleeding|vaginal clots|vaginal tissue||started several days ago|started today|"][textarea cols=70 rows=1]
Sexual Hx:
[checkbox name="sexual" value="declined|N/A||active|inactive|no new partners||known/suspected exposure|inconsistent condom use|new partner|partner w STI|non-monogamous partner||vaginal|oral|anal||previous STI|"][textarea cols=70 rows=1]
Last unprotected intercourse: [textarea cols=10 rows=1 default="N/A"]
Birth Control/HRT:
[checkbox name="birth_control" value="none||BCP|Depo|implant|IUD|BTL|condoms|"][textarea cols=70 rows=1]
Smoking:
[checkbox name="smoking" value="no|yes|"][textarea cols=70 rows=1]

HPI:
Recent History: [textarea cols=40 rows=1]
[checklist name="recent" value="stress|travel|new sexual partner|injury|PCP/UC visit|ER visit|hospitalization/surgery/procedure|new medications|antibiotic use|diagnostic study"]
Duration:
[checkbox name="duration" value="N/A|hours|days|weeks|"][textarea cols=70 rows=1]
Symptoms:
[checkbox name="sx" value="N/A||increasing in severity|remaining constant|decreasing in severity||constant|come and go|cyclic|worse with menses|worse with caffeine|"][textarea cols=70 rows=1]
Imaging:
[checkbox name="imaging" value="N/A||mammogram UTD|normal|abnormal|mammogram not UTD||ultrasound|MRI|"][textarea cols=70 rows=1]
PAP:
[checkbox name="imaging" value="N/A||normal|abnormal|unsatisfactory||EC/TZ component present| EC/TZ component absent||ASC-US|LSIL|ASC-H|HSIL|AGC|AIS|CIS||HPV POS|HPV NEG|"][textarea cols=70 rows=1]
Family Hx:
[checkbox name="family" value="N/A||breast ca|ovarian ca|colon ca|"][textarea cols=70 rows=1]
PMH:
reviewed
[checkbox name="pmh" value="noncontributory||frequent UTIs|kidney stones|incontinence||ovarian cyst|endometriosis|fibroids||breast ca||DM|immunosuppression|"][textarea cols=70 rows=1]
Pregnancy: [textarea cols=10 rows=1 default="N/A"]
[checkbox memo="pregnancy" name="notes2" value=" "][conditional field="notes2" condition="(notes2).is(' ')"][checklist name="gyn_symptoms" value="ectopic pregnancy|induced abortion|spontaneous abortion"][/conditional][textarea cols=70 rows=1]
PSH:
[checkbox name="psh" value="breast biopsy|breast implants|breast reduction||CS|salpingo-oophorectomy|hysterectomy||colposcopy|D&C|"][textarea cols=70 rows=1]


REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL: [textarea cols=40 rows=1]
[checklist name="constitutional_symptoms" value="fever|night sweats|hot flashes|unintentional wt loss"]
HEAD/FACE: [textarea cols=40 rows=1]
[checklist name="head_symptoms" value="headache|scalp swelling|trauma|facial numbness"]
EYES: [textarea cols=40 rows=1]
[checklist name="eye_symptoms" value="decrease in vision|halos|dryness|redness|discharge"]
EARS: [textarea cols=40 rows=1]
[checklist name="ear_symptoms" value="pain|pressure|discharge|wax|hearing loss|ringing"]
NOSE: [textarea cols=40 rows=1]
[checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|snoring|bleeding"]
MOUTH: [textarea cols=40 rows=1]
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache|jaw pain/clicking|changes in taste"]
THROAT: [textarea cols=40 rows=1]
[checklist name="throat_symptoms" value="sore throat|odynophagia|dysphagia|hoarseness|globus"]
NECK: [textarea cols=40 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|lightheadedness|fainting|exertional dyspnea|orthopnea|rapid wt gain|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=40 rows=1]
[checklist name="chest_symptoms" value="cough|phlegm|wheezing|pain w/ breathing|rib pain|breast swelling/lump"]
MSK: [textarea cols=40 rows=1]
[checklist name="msk_symptoms" value="myalgias|neck pain|back pain|shoulder pain|hip pain|knee pain|chronic pain/meds|joint pain/deformity|localized muscle/soft tissue pain/swelling"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|speech difficulty|tremor|seizures|urinary/bowel changes|tingling/numbness"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|withdrawal|depression|apathy|anxiety|mood swings|memory loss|insomnia"]
ENDO: [textarea cols=40 rows=1]
[checklist name="endo_symptoms" value="cold intolerance|skin dryness|hair loss"]
LYMPH/HEMA: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia"]
ALLERGIES/IMMUNE: [textarea cols=40 rows=1]
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz|h/o cancer"]
DERM: [textarea cols=40 rows=1]
[checklist name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds"]



Appearance:
[checkbox name="appearance" value="well-appearing|no signs of discomfort visible while sitting in chair|no signs of discomfort visible while ambulating & getting on/off exam table||normal built|heavy built|emaciated|frail||ill-appearing|tired-looking|short of breath|diaphoretic||good hygiene|disheveled|bizarre clothes|body odor||drowsy|appears impaired|slumped|"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN grossly intact||plethoric face|alopecia|facial droop|"][textarea cols=70 rows=1]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear||glasses|contacts|conjunctival injection|epiphora|"][textarea cols=70 rows=1]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without erythema or discharge|TMs normal in appearance|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||swollen & boggy mucosa|mucosal congestion|clear discharge|"][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions||upper denture|lower denture||poor dentition|oral ulcers|gum swelling|tooth decay|"][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline|clear pharynx w/o exudates||hoarseness|pharyngeal erythema w/o exudates|pharyngeal crowding|"][textarea cols=70 rows=1]

Neck:
[checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD|no bruit or JVD||anterior LAD|posterior LAD||thyroid enlargement|nuchal tenderness|"][textarea cols=70 rows=1]

Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion, no stridor|clear and equal breath sounds bilaterally||SOB|decreased bilaterally|wheezing|crackles|"][textarea cols=70 rows=1]

Right Breast: [textarea cols=40 rows=1]
[checklist name="right_breast" value="implant|density|skin changes|tenderness|nipple changes|nipple discharge|mass|axillary LAD|supraclavicular LAD|infraclavicular LAD"]

Left Breast: [textarea cols=40 rows=1]
[checklist name="right_breast" value="implant|density|skin changes|tenderness|nipple changes|nipple discharge|mass|axillary LAD|supraclavicular LAD|infraclavicular LAD"]

Mass:
[checkbox name="mass" value="none||r breast|left breast||round|oval|irregular||well-defined margins|ill-defined margins||less than 1 cm|1 to 3 cm|larger than 3 cm|| soft|firm|rubbery|hard||fixed|mobile|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses||tachycardia|irregular heart rhythm|systolic murmur||calf tenderness|ankle edema|varicosities|stasis discoloration|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="not examined||normal visual inspection, no distension|normal active bowel sounds|soft non-tender||protruding|surgical scar|umbilical hernia|diffuse tenderness over entire abdomen w/o RRG|direct non-rebound tenderness|colostomy in situ|"][textarea cols=70 rows=1]

MSK:
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|full weight-bearing|normal curvature & ROM in C- & L-spine for patient’s age||non-tender C-spine with good ROM|non-tender L-spine with good ROM||strength, tone, & bulk symmetrical & grossly intact|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|normal speech|no gross motor deficits||sensation symmetrical & grossly intact|extremities strong w/o atrophy, tremor or fasciculations|reflexes normoactive||antalgic gait|wide gait|shuffling gait|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="grossly intact, no rashes|no bruises|normal turgor||tattoos|body piercings|poor turgor|dry|sweaty|"][textarea cols=70 rows=1]

Pelvic Exam:
[checkbox name="pelvic" value="normal||below|declined|"][textarea cols=70 rows=1]
Vulva:
[checkbox name="vulva" value="normal||atrophy|discharge|condylomata|"][textarea cols=70 rows=1]
Vagina:
[checkbox name="vagina" value="normal||cystocele|rectocele|Bartholin's||erythema|atrophy||milky discharge|curdy discharge|greenish/yellowish discharge||active bleeding|clots|tissue in vault|"][textarea cols=70 rows=1]
Cervix:
[checkbox name="cervix" value="normal|non-tender||motion tenderness|erosions|Nabothian cyst|discharge|"][textarea cols=70 rows=1]
Uterus:
[checkbox name="uterus" value="normal||tenderness|mass|enlarged|"][textarea cols=70 rows=1]
Adnexa:
[checkbox name="adnexa" value="non-tender||tenderness|enlargement|masses|"][textarea cols=70 rows=1]
Rectal:
[checkbox name="rectal" value="declined||normal tone||hemorrhoids|masses|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm|pleasant|respectful||cooperative with exam||exam limited by urgency|exam limited by poor cooperation|exam limited by safety concerns||guarded|anxious|fearful|suspicious|hypervigilant||irritable|frustrated|restless||labile|sighing|crying||agitated|raising voice||defensive|argumentative|hostile||forceful|intense|euphoric||demanding particular medication, test, referral, or accommodation||withdrawn|indifferent|appears to be responding to internal psychotic process|"][textarea cols=70 rows=1]

Psychomotor Activity:
[checkbox name="psychomotor" value="no involuntary movements||tremor|tardive dyskinesia|tics||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles||threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard||shaking extremities|clenching fists|intense staring||standing up and/or pacing|opening door to hallway|exited exam room during exam|"][textarea cols=70 rows=1]

Speech:
[checkbox name="speech" value="clear & coherent|normal rate & rhythm||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||repetitive questions|cursing, swearing|criticisms of staff|verbal threats|"][textarea cols=70 rows=1]

Thought Process:
[checkbox name="thought_process" value="organized/linear/logical||circumstantial|tangential|perseveration|flight of ideas|preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|delusions|paranoid ideation|"][textarea cols=70 rows=1]

UA:
[checkbox name="office_ua" value="non-specific changes|normal|suggestive of UTI||leukocytes|nitrites|glucose|blood|declined||urine cx sent out|"][textarea cols=70 rows=1]
hcg:
[checkbox name="office_hcg" value="N/A||positive home test||negative clinic test|positive clinic test|declined|"][textarea cols=70 rows=1]

A/P:
[textarea cols=80 rows=8]

[comment memo="DX:
abdominal pain
abnormal pap
abortion
abscess
appendicitis
blighted ovum
breast mass
cervicitis
contusion to breast
discomfort of pregnancy
discomfort of pregnancy
dysfunctional uterine bleeding
ectopic pregnancy
endometritis
fetal demise
fibrocystic breast disease
herpes genitalis
high risk cervical neoplasm
incontinence of urine
intrauterine pregnancy
low risk cervical neoplasm
mastitis
menopause
ovarian cyst
paget's breast disease
pelvic pain
pid
prolactinemia
pyelonephritis
threatened abortion
ureterolithiasis
urinary tract infection
vaginal bleeding
vaginosis"]

PLAN OF CARE:
[checkbox name="discussed" value="POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge & f/u instructions||patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

OUTSIDE LABS:
[checkbox name="collected" value="PAP|urine|BV swab||CBC|CMP||STI|"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="none|ABX|Pyridium 100 mg TID #6|Rx for suspected vaginosis|Rx for suspected STI||electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

REVIEWED:
[checkbox name="reviewed" value="MA notes|previous visits|PMP|laboratory/diagnostic studies|"][textarea cols=70 rows=1]

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs,exam & testing findings|reporting medication side effects to clinic immediately|appropriate follow up with PCP|weight reduction|dietary changes|exercise|family planning|contraceptive options|emergency contraception|safe sex|SBE|mammogram if older than forty|osteoporosis prevention & screening|smoking cessation|"][textarea cols=70 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified during visit||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|failed to obtain old records|failed to complete referrals or testing|failed to bring medications for med review|poor compliance with medication regimen||incomplete history|vague shifting complaints|history not supported by objective findings||multiple comorbidities|recent hospitalization||polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|medication use in response to environmental stress|intolerance of multiple meds|overreliance on short-acting meds||multiple office contacts|frequent ER/UC visits||altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN||RTC 1 week|RTC 6 months|RTC 12 months||screening mammo|diagnostic mammo|diagnostic ultrasound||surgeon|GYN||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport|declined emergency transfer|left clinic before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]
HISTORY:

Purpose of Visit/CC:

Breast Sx:

GI Sx:

Menstrual Sx:

LMP:
Urinary Sx:

Vaginal Sx:

Sexual Hx:

Last unprotected intercourse:
Birth Control/HRT:

Smoking:


HPI:
Recent History:

Duration:

Symptoms:

Imaging:

PAP:

Family Hx:

PMH:
reviewed

Pregnancy:
pregnancy
PSH:



REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL:

HEAD/FACE:

EYES:

EARS:

NOSE:

MOUTH:

THROAT:

NECK:

CV:

CHEST/RESPIRATORY:

MSK:

NEURO:

PSYCH:

ENDO:

LYMPH/HEMA:

ALLERGIES/IMMUNE:

DERM:




Appearance:


Head/Face:


Eyes:


Ears:


Nose:


Mouth:


Throat:


Neck:


Lungs:


Right Breast:


Left Breast:


Mass:


CV:


Abdomen:


MSK:


Neuro:


Skin:


Pelvic Exam:

Vulva:

Vagina:

Cervix:

Uterus:

Adnexa:

Rectal:


Behavior:


Psychomotor Activity:


Speech:


Thought Process:


UA:

hcg:


A/P:


DX:
abdominal pain
abnormal pap
abortion
abscess
appendicitis
blighted ovum
breast mass
cervicitis
contusion to breast
discomfort of pregnancy
discomfort of pregnancy
dysfunctional uterine bleeding
ectopic pregnancy
endometritis
fetal demise
fibrocystic breast disease
herpes genitalis
high risk cervical neoplasm
incontinence of urine
intrauterine pregnancy
low risk cervical neoplasm
mastitis
menopause
ovarian cyst
paget's breast disease
pelvic pain
pid
prolactinemia
pyelonephritis
threatened abortion
ureterolithiasis
urinary tract infection
vaginal bleeding
vaginosis


PLAN OF CARE:


OUTSIDE LABS:


RX:


REVIEWED:


INSTRUCTED ON:


BARRIERS TO CARE:


DISPOSITION:

Result - Copy and paste this output:

Send Feedback for this SOAPnote

Your email address will not be published.

More SOAPnotes by this Author: