Soap notes

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 up for checkup at the clinic please. Below is a sample on how to do the soap notes. Use different age and information for each soap notes

This is a sample: O26.42 | Herpes gestationis, second trimester

Patient is a 30 year old female present the clinic for follow up on lab results and also for further testing. Patient has no allergy, no history of STD's, G1P0, and LMP 02/18, usually period is regular last about 5 days but not heavy, menarche at 11. Patient denied any signs of infection or vaginal bleeding at this time. Patient stated that her early pregnancy symptoms are gone. Patient is 5'3 last weight 147 pounds today she weight 150, V/S today are WNL/stable, pain 0. Patient had all her STDs done during her first trimester (HIV, herpes, chlamydia, gonorrhea, syphilis, BV, trichomoniasis) tested and all came back negative and non-reactive, Rh testing positive, pap test normal negative for HPV and G&H. Patient had all STDs repeated and is here for result and also follow up. Plan: herpes type came back positive but everything else are negative, patient denied any symptoms. Ultrasound done in office and 1 fetal noted to be moving with regular heart beat (142), patient education on herpes infection, signs to report and if become symptomatic prior vaginal birth C-section may be consider and also med like acyclovir may be prescribe to be taken at home prior labor and she stated to understand.

N81.11 | Cystocele, midline

N81.12 | Cystocele, lateral

N81.2 | Incomplete uterovaginal prolapse

N81.3 | Complete uterovaginal prolapse

N81.4 | Uterovaginal prolapse, unspecified

N81.5 | Vaginal enterocele

N81.6 | Rectocele

N81.81 | Perineocele

N81.82 | Incompetence or weakening of pubocervical tissue

N81.83 | Incompetence or weakening of rectovaginal tissue

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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 up for checkup at the clinic please. Below is a sample on how to do the soap notes. Use different age and information for each soap notes This is a sample: O26.42 | Herpes gestationis, second trimester Patient is a 30 year old female present the clinic for follow up on lab results and also for further testing. Patient has no allergy, no history of STD's, G1P0, and LMP 02/18, usually period is regular last about 5 days but not heavy, menarche at 11. Patient denied any signs of infection or vaginal bleeding at this time. Patient stated that her early pregnancy symptoms are gone. Patient is 5'3 last weight 147 pounds today she weight 150, V/S today are WNL/stable, pain 0. Patient had all her STDs done during her first trimester (HIV, herpes, chlamydia, gonorrhea, syphilis, BV, trichomoniasis) tested and all came back negative and non-reactive, Rh testing positive, pap test normal negative for HPV and G&H. Patient had all STDs repeated and is here for result and also follow up. Plan: herpes type came back positive but everything else are negative, patient denied any symptoms. Ultrasound done in office and 1 fetal noted to be moving with regular heart beat (142), patient education on herpes infection, signs to report and if become symptomatic prior vaginal birth C-section may be consider and also med like acyclovir may be prescribe to be taken at home prior labor and she stated to understand. N81.11 | Cystocele, midline N81.12 | Cystocele, lateral N81.2 | Incomplete uterovaginal prolapse N81.3 | Complete uterovaginal prolapse N81.4 | Uterovaginal prolapse, unspecified N81.5 | Vaginal enterocele N81.6 | Rectocele N81.81 | Perineocele N81.82 | Incompetence or weakening of pubocervical tissue N81.83 | Incompetence or weakening of rectovaginal tissue ...
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School: Duke University

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