SOAP NOTE

– 39-year-old female 29 weeks GA

– G2P0A1

– office visit date is 5/22/22

– Pt in the clinic for follow up 1-hour GTT result., 1 hr gtt result failed ( tested last week on 5/15/22 at 28 weeks)

– Weight gain of 25lbs since initial OB visit

Subjective Data

– Include HPI Include her non-pregnant medical health history and her previous pregnancy & delivery history

– Include ROS

Objective Data

– Include vital signs (Blood Pressure 118/80, HR 76, Pulse Ox 100, temp 97.8)

– Include point of care testing (POCT)- what do expect to see here?

– Include any labs and diagnostic testing done in the clinic

– Include an appropriate exam

Assessment

– Include ICD 10 code

– Include DDX

Plan

– Include follow up plan/ referral

– Include medication (if appropriate)

– Include education, teaching, follow up, and referral (if appropriate)