OBGYN Soap Notes 5

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 the sample :

Z39.2 | Encounter for routine postpartum follow-up

14. Patient is a 33 year old female present to the clinic for postpartum follow-up. Patient had a C-section 6 weeks ago. Plan: Vital signs WNL, C-section horizontal site clean, dry and intact, open to air, vaginal exam done very minimal drainage noted but odorless, bilateral breast are slightly tender and patient stated that she is breast feeding. Patient stated that the baby is ok and has an appointment schedule to go see the pediatrician soon. Birth control discussed, signs to report and infection control management.

N39.42 | Incontinence without sensory awareness

N39.43 | Post-void dribbling

N39.44 | Nocturnal enuresis

N39.45 | Continuous leakage

N39.46 | Mixed incontinence

N39.490 | Overflow incontinence

N39.498 | Other specified urinary incontinence

N39.8 | Other specified disorders of urinary system

N39.9 | Disorder of urinary system, unspecified

O00.0 | Abdominal pregnancy

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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 the sample : Z39.2 | Encounter for routine postpartum follow-up Patient is a 33 year old female present to the clinic for postpartum follow-up. Patient had a Csection 6 weeks ago. Plan: Vital signs WNL, C-section horizontal site clean, dry and intact, open to air, vaginal exam done very minimal drainage noted but odorless, bilateral breast are slightly tender and patient stated that she is breast feeding. Patient stated that the baby is ok and has an appointment schedule to go see the pediatrician soon. Birth control discussed, signs to report and infection control management. N39.42 | Incontinence without sensory awareness N39.43 | Post-void dribbling N39.44 | Nocturnal enuresis N39.45 | Continuous leakage N39.46 | Mixed incontinence N39.490 | Overflow incontinence N39.498 | Other specified urinary incontinence N39.8 | Other specified disorders of urinary system N39.9 | Disorder of urinary system, unspecified O00.0 | Abdominal pregnancy ...
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Tutor Answer

Expert001jk
School: Carnegie Mellon University

Attached.

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.
Z39.2 | Encounter for routine postpartum follow-up
Patient is a 33 year old female present to the clinic for postpartum follow-up. Patient had a Csection 6 weeks ago. Plan: Vital signs WNL, C-section horizontal site clean, dry and intact, open
to air, vaginal exam done very minimal drainage noted but odorless, bilateral breast are slightly
tender and patient stated that she is breast feeding. Patient stated that the baby is ok and has
an appointment schedule to go see the pediatrician soon. Birth control discussed, signs to
report and infection control management.
N39.42 | Incontinence without sensory awareness
Adult female patient present at the clinic with complains of passing urine unknowingly. She
reports to just find out that she has passed urine not knowing. Plan: abdomino-pelvic
ultrasound done. Impression: incontinence without sensory awareness. Plan: catheterize the
patient to help in passage of urine and drain freely from the bladder for collection. Patient told
to come back after two days for change of catheter.
N39.43 | Post-void dribbling
14 year old female present at the clinic for check up...

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Anonymous
awesome work thanks

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