Description
Please use below information to complete Soap Note. I have attached the template that Needs to be filled. I have also attached an example provided. Also attached is grading rubric.
For the physical exam: Please do a focused exam. For this patient breast, genitourinary, HEENT did not need to be completed.
Diagnosis: Please complete a description for each diagnosis
Medications: Please enter name, dose and frequency
Please enter a description for the diagnoses.
Also elaborate more on the plan and patient education
Rotation Type: | NSG6430 – FNP Women’s Health |
Diagnostic Codes: | Z12.4 | Encounter for screening for malignant neoplasm of cervix |
Patient Age: | 18 Years |
Patient Sex: | F |
Patient Ethnicity: | White |
Student Participation: | 25% |
Chief Complaint: | pt comes in for her first pap |
Reason for Visit (Check at least one): | Gynecologic Care New Consultation Screening/Health Promotion |
Procedure: | – |
Skills/Procedures (Select All That Apply): | Pap Smear STD & HIV Screening/Counseling |
Time with Patient (min): | 60 |