UTI in-depth soap

[text size="3"] year old pt presents to the clinic today with symptoms of a uti. LMP [text name="variable_1" default="sample text"].
[checkbox value="Pt complains of"]
[checkbox value="dysuria|frequency|urgency|nocturia
|urge incontinence|stress incontinence|post-micturition dribble|hematuria|cloudy urine|malodorous urine| fever|chills|vaginal discharge|Pelvic pain|flank pain"]. [text name="variable_1" default="sample text"].
[checkbox value="Pt denies"]
[checkbox value="dysuria|frequency|urgency|nocturia
|urge incontinence|stress incontinence|post-micturition dribble|hematuria|cloudy urine|malodorous urine| fever|chills|vaginal discharge|Pelvic pain|flank pain"].[text name="variable_1" default="sample text"].
ROS: negative unless otherwise noted in HPI
[OBJECTIVE:
General: Pleasant disposition. [text]
HEENT: Normocephalic, Face is symmetrical [text]
Skin: Normal for ethnicity, no evidence of sweating/perspiration. [text]
Respiratory: No evidence of increased work of breathing.  [text]
Musculoskeletal: Moves all upper extremities equally. [text] 
Neuro: Alert and oriented x3; speaking in full sentences.  [text]
Allegies: [text name="variable_1" default="sample text"].
[checkbox value="UA|home urine test strip|PVR|KUB|RUS|CT of ABD/Pelvis with/without contrast|CT of ABD/Pelvis without contrast"] obtained and reviewed.  
[checkbox name="variable_1" value="option A|option B|option C"] Test results revealed: [text name="variable_1" default="sample text"]
[checkbox name= value="Urine culture ordered"], 
[checkbox value="will call pt when culture has resulted, if postive culture, will prescribe appropriate abx therapy at that time|will start pt on abx therapy at this time and review therapy choice when culture results, and call if change in abx therapy is needed"]
Pt to f/u in clinic in [text size="3"] 
[checkbox value="days|week(s)|month(s)|year(s)"].
Informed the pt if symptoms worsen to proceed to urgent care or ER for immediate follow-up. Pt counseled on medication side effects and on how to take medicine. 
year old pt presents to the clinic today with symptoms of a uti. LMP .

. .

..
ROS: negative unless otherwise noted in HPI
[OBJECTIVE:
General: Pleasant disposition.
HEENT: Normocephalic, Face is symmetrical
Skin: Normal for ethnicity, no evidence of sweating/perspiration.
Respiratory: No evidence of increased work of breathing.
Musculoskeletal: Moves all upper extremities equally.
Neuro: Alert and oriented x3; speaking in full sentences.
Allegies: .
obtained and reviewed.
Test results revealed:
,

Pt to f/u in clinic in
.
Informed the pt if symptoms worsen to proceed to urgent care or ER for immediate follow-up. Pt counseled on medication side effects and on how to take medicine.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.41, 22 form elements, 104 boilerplate words, 13 text boxes, 9 checkboxes, 62 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: