OBGYN Soap Notes 5

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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References:

Nursing Standards

Nursing and Midwifery Board of Australia. (2018). Code of conduct for midwives. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Clinical Guidelines

Guideline Adaption Committee. (2016). Clinical practice guidelines and principles of care for people with dementia. NHMRC Partnership Centre for Dealing with Cognitive and Related Function Decline in Older People. https://cdpc.sydney.edu.au/wp-content/uploads/2019/06/CDPC-Dementia-Guidelines_WEB.pdf

Living Guideline

Stroke Foundation. (2022). Australian and New Zealand living clinical guidelines for stroke management – chapter 1 of 8: Pre-hospital care. https://app.magicapp.org/#/guideline/NnV76E

Evidence-based practice

BMJ Best Practice

Goldfarb, S., & Josephson, M. (2020). Cystic fibrosis. BMJ Best Practice. https://bestpractice.bmj.com/

Schub, T., & Cabrera, G. (2018). Bites: Head lice [Evidence-based care sheet]. Cinahl Information Systems. https://www.ebscohost.com

Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation. http://www.hcmarketplace.com/supplemental/3737_browse.pdf

JBI: Evidence summary

Swe, K. K. (2022). Blood glucose levels: Self-monitoring [Evidence summary]. JBI EBP Database. https://jbi.global

JBI: Best practice information sheet

Bellman, S. (2022). Experiences of living with juvenile idiopathic arthritis [Best practice information sheet]. JBI EBP Database, 24(1), 1-4.

Cochrane Database of Systematic Reviews

Srijithesh, P. R., Aghoram, R., Goel, A., & Dhanya, J. (2019). Positional therapy for obstructive sleep apnoea. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010990.pub2

Drug Information

Codeine. (2023, January). In Australian medicines handbook. Retrieved February 2, 2023, from https://amhonline.amh.net.au

Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm

 

Dartmouth Writing Program. (2005). Writing in the social sciences. http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml

Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing, 13(1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html

Wagner, D. (n.d.). Why writing matters in nursing. https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/

Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html

Perth Children’s Hospital. (2022, April). Appendicitis [Emergency Department Guidelines]. Child and Adolescent Health Service. https://www.pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Appendicitis

Department of Health. (n.d.). Who is being active in Western Australia? https://ww2.health.wa.gov.au/Articles/U_Z/Who-is-being-active-in-Western-Australia

Donaldson, L. (Ed.). (2017, May 1). Healthier, fairer, safer: The global health journey 2007-2017. World Health Organisation. https://www.who.int/publications/i/item/9789241512367

NCBI Bookshelf

Rodriguez Ziccardi, M., Goyal, G., & Maani, C. V. (2020, August 10). Atrial flutter. In Statpearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540985/

Royal Perth Hospital. (2016). Procedural management: Pre and post (24-48 hours) NPS. Canvas. https://courses.ecu.edu.au

 

 

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