Soap notes

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 a sample: O26.42 | Herpes gestationis, second trimester

Patient is a 30 year old female present the clinic for follow up on lab results and also for further testing. Patient has no allergy, no history of STD’s, G1P0, and LMP 02/18, usually period is regular last about 5 days but not heavy, menarche at 11. Patient denied any signs of infection or vaginal bleeding at this time. Patient stated that her early pregnancy symptoms are gone. Patient is 5’3 last weight 147 pounds today she weight 150, V/S today are WNL/stable, pain 0. Patient had all her STDs done during her first trimester (HIV, herpes, chlamydia, gonorrhea, syphilis, BV, trichomoniasis) tested and all came back negative and non-reactive, Rh testing positive, pap test normal negative for HPV and G&H. Patient had all STDs repeated and is here for result and also follow up. Plan: herpes type came back positive but everything else are negative, patient denied any symptoms. Ultrasound done in office and 1 fetal noted to be moving with regular heart beat (142), patient education on herpes infection, signs to report and if become symptomatic prior vaginal birth C-section may be consider and also med like acyclovir may be prescribe to be taken at home prior labor and she stated to understand.

N81.11 | Cystocele, midline

N81.12 | Cystocele, lateral

N81.2 | Incomplete uterovaginal prolapse

N81.3 | Complete uterovaginal prolapse

N81.4 | Uterovaginal prolapse, unspecified

N81.5 | Vaginal enterocele

N81.6 | Rectocele

N81.81 | Perineocele

N81.82 | Incompetence or weakening of pubocervical tissue

N81.83 | Incompetence or weakening of rectovaginal tissue

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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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