SOAP NOTE – 39-year-old female 29 weeks GA – G2P0A1 – office…
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)
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