Women health soap note
Nursing is a field that requires adequate and effective documentation. Soap note is a method of documenting patient information when diagnosing to determine the best kind of medication (Podder, Lew, Ghassemzadeh, 2020). The following is a soap note for a woman who visited the hospital.
Name: Jane Smith
Marital Status: Single
Chief complain: The patient states that she needed a birth control checkup and pap test.
History of illness: The patient explained that she had her last birth control when she was 6 years and she has been dating for five years. Her last pap years ago indicated a normal condition.
Past medical history (PMH):
Immunization: Up to date immunization.
Previous screening: she had a normal pap condition in 2016. Her mother is a cancer survivor who was diagnosed at the age of 35.
Objective data (O):
Constitutional: BP-111/68, weight- 75 lbs, Height: 5.5m,
Eyes: normal sclerae white, extraocular movements
Ear: normal external appearance, no swelling.
Mouth: Mucous membranes, 3 missing teeth.
Throat: No inflammation, exudate, Tonsils
Nose: No mucous, Nares patients.
General palpation: No subcutaneous tissue masses present.
Genitourinary: No distention noted.
V26.08 Advice on contraceptive management.
The patient requested an advice on her contraceptives and advise on what to do when she misses medication.
The patient needed advice on her pap condition. She is sexually active and hence pap smears are recommended regularly.
Medication profile: Tri Sprintec
Indication: Pregnancy prevention.
Dosage: One tablet per day.
Follow up: One year.
Podder, V., Lew, V., Ghassemzadeh, S. (2020). SOAP Notes. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/
Patient encounters for family planning and contraceptives is a common occurrence in women’s health, thus it is important as APRNs to be able to effectively manage these visits and document findings appropriately.
What were the findings noted from the patient for the ROS?
Also, what were the detailed objective findings from the physical exam?
Lastly, what exactly is family planning and PAP smear? Please include detailed descriptions of both.
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.Read more
Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.Read more
Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.Read more
Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.Read more
By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.Read more