‘PEOB
GEN: Well-appearing _-year-old female who appears a stated age, sitting in hospital bed, relaxing comfortably, no acute distress HEENT: Normocephalic, atraumatic, pupils equal and round, hearing grossly normal Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs, no peripheral edema PULM: Symmetric chest rise, no increased work of breathing, lungs clear to auscultation bilaterally, no cough/crackles/wheeze/rhonchi GI: Gravid, flat, normoactive bowel sounds, nondistended, nontender, no masses or hepatosplenomegaly MSK: Normal gross movement of bilateral upper and lower extremities SKIN: Pink, warm, dry; no rashes NEURO: Alert and oriented, CN II-XII grossly intact, no focal neurologic deficit PSYCH: Cooperative, answers questions appropriately, pleasant affect Fundal height: _ cm FHT: _ per M- mode on U/S Bedside ultrasound: _ singleton pregnancy
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 123 boilerplate words
More SOAPnotes by this Author:
Send Feedback for this SOAPnote