OBGYN Soap note

Anonymous
timer Asked: Aug 23rd, 2018
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Question Description

Hello follow instruction please can you use these ICD-10 Codes to make up 10 Soap notes with each of them for OBGYN patients coming for checkup at the clinic please. Below is a sample on how to do the soap notes.

This is a soap note sample :Z30.432 | Encounter for removal of intrauterine contraceptive device Patient is a 30 year old female, present to clinic for follow up after a cooper IUD was placed 6 months ago. Patient has no previous health history including STD's, she is G2G2 via vaginal birth. Patient stated that she been having some vagina discharge and is concerned of infection. Plan: V/S WNL, weight 125 pounds, height 5’2. A speculum inserted inside the vagina and small amount of discharge noted with foul odor, external vagina has no lesions, IUD string is visible and was removed and patient agreed, vagina culture done, Flagyl 500 mg by mouth BID X 7 days ordered, next appointment in 2 weeks.

  • Z32.00 | Encounter for pregnancy test, result unknown
  • Z32.01 | Encounter for pregnancy test, result positive
  • Z32.02 | Encounter for pregnancy test, result negative
  • Z32.2 | Encounter for childbirth instruction
  • Z32.3 | Encounter for childcare instruction
  • D06.0 | Carcinoma in situ of endocervix
  • XD06.1 | Carcinoma in situ of exocervix
  • XD06.0 | Carcinoma in situ of endocervi
  • N81.0 | Urethrocele
  • N81.10 | Cystocele, unspecified

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Hello follow instruction please can you use these ICD-10 Codes to make up 10 Soap notes with each of them for OBGYN patients coming for checkup at the clinic please. Below is a sample on how to do the soap notes. This is a soap note sample :Z30.432 | Encounter for removal of intrauterine contraceptive device Patient is a 30 year old female, present to clinic for follow up after a cooper IUD was placed 6 months ago. Patient has no previous health history including STD's, she is G2G2 via vaginal birth. Patient stated that she been having some vagina discharge and is concerned of infection. Plan: V/S WNL, weight 125 pounds, height 5’2. A speculum inserted inside the vagina and small amount of discharge noted with foul odor, external vagina has no lesions, IUD string is visible and was removed and patient agreed, vagina culture done, Flagyl 500 mg by mouth BID X 7 days ordered, next appointment in 2 weeks. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Z32.00 | Encounter for pregnancy test, result unknown Z32.01 | Encounter for pregnancy test, result positive Z32.02 | Encounter for pregnancy test, result negative Z32.2 | Encounter for childbirth instruction Z32.3 | Encounter for childcare instruction D06.0 | Carcinoma in situ of endocervix XD06.1 | Carcinoma in situ of exocervix XD06.0 | Carcinoma in situ of endocervi N81.0 | Urethrocele N81.10 | Cystocele, unspecified ...
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Prof_karsis
School: Purdue University

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