Gynecological soap note Template S: cc

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LPH 11/11/2010

Gynecological SOAP Note Template
S: CC: Use pt’s words in quotation marks
HPI: Include onset, duration, progression, timing, amount, aggravating factors, alleviating factors, treatments already tried, previous h/o similar sx? &c. Include pertinent negatives. History of contraceptive use.
OB/Gyn History: Include anything pertinent to the CC or that would affect tx plan.
Menstrual history: LMP!, age at menarche, length of cycle, average number of days of menses, characteristics of flow, regularity of cycles, descriptions of any irregularities and/or accompanying symptoms. (Normal cycle: 21 – 35 days, menses last 4 – 7 days)

Pregnancy history: GTPAL. Chronological order: year, duration, type of birth, sex, baby’s weight, complications, is the child alive and well? TABs, SABs, ectopics, molar pregnancies.
History of STIs: what type of infections, what tx, how frequently, complications? & screen for HIV risk. Number of current sexual partners and during lifetime. condom use?

Does she douche?

Gyne problems/procedures:

Urologic health: occurrence and frequency of bladder & UTI & kidney infections, incontinence
Previous Paps? Date of last Pap, results. Ever had an abnormal Pap? What follow up occurred and have subsequent screenings been normal?
Sexual history: Is she sexually active and if so with men, women, or both? Is she satisfied with her current sexual function? Does she or her partner have any concerns or problems? History of sexual assault?
Contraceptive use: is she currently using a method? Is she satisfied with it or does she desire a change? Discuss her past methods if relevant for the visit.
Abnormal symptoms: fully describe, e.g. pelvic pain, noting relationship in time with menstrual cycle, association with sex, tampon use, or other factors. Describe any vaginal bleeding not associated with menses.

General Medical History: Include any pertaining to the CC or that would affect tx plan (Ex: noncontributory or negative).

Current illnesses or disease

Past hospitalizations

Prior surgical procedures

Immunization status

Previous serious illnesses

Need for any well-woman recommendations: mamo, colpo, glucose, lipid panel, TSH, vaccines? Etc

Medications: OTC, rx, herbal, &c

Allergies: meds, environmental, latex, shellfish, iodine
FMH: Include any pertinent to the CC or that would affect tx plan (alcoholism, cancer, endocrine, genetic/chromosomal, hematological, mental retardation, CVD, congenital anomalies, GI, lung, neuro, renal, psychiatric, multiple gestation, DV. (Ex: noncontributory)
Psychosocial/Social History/Habits: Include use of tobacco, drugs, ETOH. Current living situation. Occupational, exposure to hazards. Relationships, recent sexual history/partners, monogamous?

Safety: Use of seat belts, helmets, firearms in household; DV/IPV
Chart Review: Relevant information from chart, place either in S or O

O: Vital signs, weight, height, BMI

General: Observation of pt – is she anxious, nervous, in pain? If so, identify the behaviors she demonstrates. Does she look older than stated age? State of health (ex: malnourished, well-nourished, obese)? Can use NAD

PE: Include only systems r/to CC. Organize by systems and list in head to toe order. Sometimes no exam is necessary, and this should be noted (e.g., “deferred, not examined”)

HEENT: Normocephalic. EOMI. PERRLA. TMs pearly gray bilaterally. No nasal drainage or lesions. Mouth and throat without lesions or exudates, teeth in good repair, gums pink.

Neck: No lymphadenopathy or thyromegaly. (Ex: euthyroid)

Chest: CTA throughout.

Heart: RRR, no m/g/r

Breast exam: Size (if remarkable, e.g. small, large, pendulous), nipples, symmetry. Skin changes (rashes, lesions, dimpling, retraction). Note masses, lumps, or tenderness. Description of a mass: Location (can draw picture or describe location as on a clock face), size, shape, consistency, mobility distinctness, nipple, skin over lump, tenderness, lymphadenopathy. (Ex: No masses, lumps, or tenderness, symmetrical without discharge. Axilla WNL)

Abdomen: Non-tender, no hepatosplenomegaly

Extremities: FROM ? no varicosities

Pelvic exam:

External Genitalia: Mons including hair distribution (triangle escutcheon, no lesions), labia majora and minora, clitoris, Bartholin’s and Skene’s glands (often grouped with urethra as BUS), hymen, introitus, perineum. Piercings?

Vagina: Color, rugation, odor, tone. (Cystocele, rectocele, discharge, inflammation, lesions, masses) (Ex: rugated, pink, no lesions or discharge, good tone)

Cervix: Color, os, position, texture, mobility. (Lesions, masses, inflammation, discharge, friability or bleeding, cervical motion tenderness/CMT) (Ex: No CMT, lesions, ectropion, discharge?, patent os)

Uterus: Position, size, consistency, mobility. (Masses or tenderness) (Ex: Small, firm, midline, smooth and mobile, non-tender)

Adnexae: Size & shape. (Masses or tenderness) (Ex: bilaterally nontender, no masses)
Diagnostic: List results that you already have (lab, x-ray, &c)

A: Diagnosis:

Well woman exam

Undesired fertility (for gyne/birth control visit)? etc

P: Diagnostic (lab, x-ray, &c) that you plan for this pt (Ex: Pap smear, GC/CT)

Treatment (meds, diet, exercise, &c) (Ex: Continue Ortho Tri-Cyclen x 1 yr)

Education (Ex: nutrition, exercise, calcium intake; BSE)

Consultations, Collaborations, or Referrals

Follow-up: Must state when the pt will be seen again. (Ex: RTC in 1 yr for annual exam and prn)

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