Clinical SOAP Notes: Irregular Menstruation
The Soap Note must follow all the steps as an example.
use as example only the last one : herpes Zoster
and this is the case.
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| Procedures/Skills (Observed/Assisted/Performed) | |
| ICD-10 Diagnosis Codes | |
| #1 – | N92.6 – IRREGULAR MENSTRUATION, UNSPECIFIED |
| #2 – | N92.1 – EXCESSIVE AND FREQUENT MENSTRUATION WITH IRREGULAR CYCLE |
| CPT Billing Codes | |
| #1 – | 99213 – OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN |
| #2 – | 2010F – VITAL SIGNS DOCUMENTED AND REVIEWED |
| #3 – | 80053 – COMPREHENSIVE METABOLIC PANEL |
| #4 – | 1119F – INITIAL EVALUATION FOR CONDITION |
| #5 – | 99071 – PATIENT EDUCATION MATERIALS PROVIDED BY PHYSICIAN/OTHER PROFESSIONAL |
| #6 – | 85027 – BLOOD COUNT; COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, & PLATELET) |
| #7 – | 0555F – SYMPTOM MANAGEMENT PLAN OF CARE DOCUMENTED |
| #8 – | 76856 – ECHOGRAPHY, PELVIC (NONOBSTETRIC), REAL TIME W/IMAGE DOCUMENTATION; COMPLETE |
| #9 – | 88155 – CYTOPATHOLOGY, SLIDES, CERVICAL/VAGINAL, HORMONAL EVAL |
| #10 – | 83036 – HEMOGLOBIN; GLYCOSYLATED (A1C) |
| Birth & Delivery |
| Medications | |
| # OTC Drugs taken regularly: | 0 |
| # Prescriptions currently prescribed: | 0 |
| # New/Refilled Prescriptions This Visit: | 0 |
| Types of New/Refilled Prescriptions This Visit: Endocrinology – Minerals/vitamins |
Adherence Issues with Medications: Complexity/demands of treatment Financial concerns Knowledge deficit |
| Other Questions About This Case | |
| Nutritional Status: | Good |
| Smoking Assessment: | Non-smoker |
| Trimester: | |
| Patient’s primary language: | Spanish |
| Ethnicity: | Spanic/Latin |
| History of present illness (HPI): | Pt who comes today because she is having irregular periods for 6 months |
| Other current meds/herbals/vitamins: | Multivitamins |
| TIme spent performing family assessment: | 5 min |
| Blind : | |
| Deaf: | |
| Screen for drugs: | Yes |
| Screen for alcohol: | Yes |
| Homeless: | |
| Religious practices affecting care: | Yes |
| Immunizations up to date: | Yes |
| Patient is non-ambulatory: | |
| Patient is ambulatory: | Yes |
| Antepartum new: | |
| Peri/postmenopausal visit: | |
| Breastfeeding eval and counseling: | |
| Early postpartum visit < 1 week: | |
| Home birth: | |
| Newborn assessment: | |
| Clinical Notes | |
| @1 y/o female who comes today because she is having irregular periods in time and in bleeding, as per pt referred, she is having heavy menses when she has the periods that is not every month. She denies weakness or dizziness, no nausea or headache. She states she is having acne before periods that disappear with it. No other symptoms is referred. NKA No medication used Vital in the normal range. review of systems Pt refers to get irregular periods with heavy menses using 2boxes of S+ tampons or sometimes more. Physical exam: Normal physical appearance, hair with normal implantation and distribution, no sin lesions or color change. Normal resp system. Normal Cardiovascular system. Normal extremities and spine, no gait problems. Grossly normal cranial nerves. No psychiatric problems noticed. GU: Normal external genital. Pt refused the rest of the exam Diag: Irregular menstruation. Plan: labs ordered, CBC, CMP, A1C, Hormone levels. Follow up in 15 days to check the results and for the treatment /referrals. |
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