Gynecologic Health Soap Note

Gynecologic Health Soap Note

Gynecologic Health Soap Note: Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :

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Subjective: What details did the patient provide regarding her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters for this patient , as well as a rationale for this treatment and management plan.

Very Important:  Reflection notes: What would you do differently in a similar patient evaluation?

Reference

Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.

Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)

Chapter 7, “Care of the Woman with Reproductive Health Problems”

“Care of the Woman with Dysmenorrhea” (pp. 366–368) 

“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418)

Gynecologic Health Soap Note
S: T.L. is a 45 y/o Caucasian female who presents with perimenopausal symptoms including hot
flashes, night sweats and anxiety. She reports that these symptoms have occurred over the last
years and are worse particularly one week prior to menses. Menses is regular, occurring every 28
days, and is very light and short, requiring one pad/day and lasting 3-5 days s/p a hysteroscopic
endometrial ablation in 2016. Denies vaginal dryness, dyspareunia, memory loss, insomnia,
dysuria. Denies smoking or illicit drugs. Reports occasional alcohol use. No hx of abnormal
PAPs or STDs. Denies any other PMH or any FHx of colon, uterine, breast, or ovarian cancers.
Allergy to PCN.
O: Constitutional: Appears obese and mildly anxious. No signs of apparent distress present. Alert
and oriented.
Vital Signs: BP 137/88mmHg, HR 76/bpm, RR 19, Temp 97.4, Wt. 268lbs., Ht. 67”, BMI 42.
Skin: Warm, pink, and dry. No suspicious lesions or nevi.
Neck: Supple and symmetric. No lymphadenopathy. Thyroid not palpable, no masses or lumps.
Cardiovascular: Heart RRR, normal S1 and S2. No rubs, murmurs, or gallops.
Respiratory: Lungs CTAB. Respirations easy, non-labored.
Abdomen: Protuberant, soft, nontender and nondistended without guarding, rigidity or rebound
tenderness. No palpable hepatosplenomegaly.
Extremities: Peripheral circulation is normal with no evidence of clubbing and cyanosis. No
edema bilaterally. No varicosities noted.
Breasts: Symmetric in shape and size. No dimpling of the breasts bilaterally. No lesions or
puckering of the breasts. No dominant masses noted. No discharge, inversion or lesion of the
nipples bilaterally. Axillae: No lymphadenopathy or mass of the axillae, infra/supraclavicular
bilaterally.
Pelvic Exam: External genitalia- hair distribution of normal female pattern. No vulvar erythema
or lesions. Vagina: walls pink, moist, rugae present, well estrogenized w/o lesions. No prolapses
noted. Cervix: Without lesions, discharge or bleeding. No polyps. Bimanual: Suboptimal due to
body habitus. Neg CMT. Uterus midline, mobile, soft and nontender. No adnexal tenderness or
masses.
A: Perimenopausal Vasomotor Symptoms
P: Pharmacologic: Venlafaxine Hydrochloride (Effexor) – 37.5mg ER 1 tab PO Daily. If
symptoms do not resolve or worsen, can also consider options such as hormone replacement
therapy (with progesterone included since she has an intact uterus), Gabapentin, Clonidine,
Vistaril.
Nonpharmacologic: Avoid personal triggers (hot drinks, caffeine, spicy foods, alcohol, emotional
situations), exercise/yoga, acupuncture, and herbals (soy, black cohosh). Encourage weight loss.

Notes : Gynecologic Health Soap Note

Why Do We Write SOAP Notes?

Proper charting is an essential form of communication among healthcare professionals. Healthcare providers need to be fluent in SOAP notes to provides concise and complete documentation that should describe what you observed, what data you collected, and what you did. Take full credit for your hard work!

SOAP note

  • S: Subjective Data
  • O: Objective Data
  • A: Assessment (Diagnosis)
  • P: Plan

Subjective data is the description that the patient gives you. It cannot be measured.

Subjective data is what the patient tells you.

Here are examples of what comes after Subjective data:

  • Demographics: age, sex
  • Chief Complaint (CC): Why are they here? Use their words (“I am having chest pain”; “I think I have gained weight”)
  • History of Present Illness (HPI): All medical information relevant to today’s particular complaint.
  • Obstetric History (ObHx): Provide their pregnancy history(Gravida/Para or GTPAL- Gravida Term Birth, Preterm Birth, Abortions, Living Children)
  • Past Medical History (PMH): Any medical condition in their past such as Hypertension, Diabetes.
  • Past Surgical History (PSH): Any surgical condition in their past
  • Family History (FamHx): Relevant health history related to the family. Especially the genetically inherited diseases.
  • Social History: Alcohol, tobacco use, recreational drug use, seatbelt safety, guns, domestic history, mental health history.

Data that the health provider can directly observe. It CAN be measured

General appearanceIs the patient alert and oriented? Is the patient in mild, moderate, or severe distress? Does the patient appear healthy and well-nourished?

Vital signs: blood pressure, pulse, respiration, temperature, height, weight.

Physical exam findings:

  • Head, Ears, Ears, Nose, Throat (HEENT): Is the head normocephalic? Are there any issues with sinuses? What does the tympanic membrane look like in the ear? Is there any discharge from the ears, eyes, or nose? Describe it. What do the mucous membranes look like of the mouth, nose, and throat? Are the nares patent? Is there exudate or swelling from the tonsils?
  • Neck: Describe ROM, skin, thyroid.
  • Heart: Describe the rate and rhythm. Are there any murmurs or additional heart sounds? Capillary refill? Bruits?
  • Lungs: Are there any crackles or wheezes? Are they clear to auscultation?
  • Abdomen: Is it soft? Is it tender? Is it distended? Can you hear bowel sounds in all four quadrants? Describe the inguinal area.
  • Musculoskeletal: Is the spine aligned? ROM of the spine? Is there erythema or tenderness? Tenderness? Muscular development? Gait?
  • Back: Examine the spine. Gait? Posture? Spinal deformity? Are the spinal muscles symmetric? Muscle spasms? CVA tenderness?
  • Extremities: Think of both upper and lower. Are there any deformities or joint abnormalities? Are the pulses intact? ROM? Are there any varicosities? Is there any cyanosis, clubbing, or edema? Describe reflexes.
  • Neurologic: Are there any neurologic issues? HA? Visual disturbances like blurred vision, floaters, or light disturbances?
  • Skin: Is it warm or cool to touch? Moist or dry? Describe any rash or tenderness.
  • Fetus: Is the patient pregnant? Bimanual exam results? Fetal heart tone range? Are they feeling fetal movement? What is the EDD or estimated gestational age?

Imaging: Include any imaging results from the prior visit like the dating, Nuchal Translucency (NT), Anatomy or growth ultrasounds.

Assessment

Assessment means diagnosis.

Under assessment, include:

  • Diagnosis
  • Differential diagnosis
  • Pertinent positives and negatives

The diagnosis can be as simple as intrauterine pregnancy and gestational age or specific to a disease process. If you are concerned about differentials, these should be listed too.

Plan

What will you do to treat the diagnosis?

  • Medications prescribed
  • Diagnostics ordered: labs, ultrasound, radiology
  • Therapeutic: diet, activity
  • Patient education provided
  • Referrals: specialties, therapies, other services
  • Disposition: Discharge home, continue monitoring, transfer units.

Initial Prenatal Visit (First OB antepartum)

Subjective (S)

Demographics: 19 yo G1P1000 @ 10w2d by irregular periods and unsure LMP

CC: Unintended pregnancy, pt is accepting but overwhelmed. Unmarried, FOB involved. Presenting for OB care as a new patient, first antepartum visit.

HPI Believes LMP to be around: 1/24/2015 (“sometime between Valentine’s day and New Year’s Eve, probably the last week of January”). Unsure intercourse timing. Positive HPT: 3/17/2015 because she wanted to see if she “should have a green beer or not.” Healthy, well-nourished female. C/o nausea, first thing in the morning for the last two weeks. Amenorrhea, increased frequency of urination, fatigue and breast tenderness began about four weeks ago. Denies dizziness, HA, visual disturbances, edema. C/o nausea and vomiting in early AM and after large meals. Denies vaginal discharge, odor, bleeding, and cramping. Eats fruits and hydrates appropriately. Pt is not currently exercising.

OB/GYN History: G1P0. No hx of STI.

Yearly pap: Never had Pap, no Pap indicated at <21 yo per ACOG guidelines.

Past medical/surgical History:

  • Allergies: NKDA
  • No medical Hx
  • Surgical Hx: wisdom teeth removed 2012
  • Chewable PNV PO daily with 800 mcg Folic Acid
  • Flu immunization October 2014, TDaP 2008

FH (Family History)

  • Father died of colon cancer at age 54 (2009)
  • Mother had cervical cancer (2010), is alive and stable
  • Maternal Grandfather with Type II diabetes & neuropathy. Alive.
  • Maternal Grandmother died in MVA in 2017. No health issues.
  • Unknown paternal grandparents.

SH (Social/Personal History) Single, attending college PT for nursing, works FT as a waitress, no drug use, 5-7 glasses of beer per week before pregnancy (1-2 at one time). Has not consumed alcohol since 3/1/2015. Never smoker. Christian, non-denominational No domestic violence. Does not have a cat, no litter box. Personal – Denies History of abuse, mental illness, depression, anxiety, or eating disorders.

Objective (O)

General appearance: The patient is alert, oriented X 4, in no acute distress.

BP 118/68 P 68 Resp rate 18

Ht: 64” Wt: 115 lbs BMI: 19.7

HEENT: Head is normocephalic. The sinuses are nontender. Pupils are equal and reactive. The nares are patent. The oropharynx is clear without lesions.

NECK: Supple without lymphadenopathy. Thyroid normal size, without nodules.

HEART: Regular rate and rhythm.

LUNGS: CTA. No crackles or wheezes are heard.

ABDOMEN: Soft, nontender with good bowel sounds heard. Inguinal area is normal.

EXTREMITIES: Without cyanosis, clubbing or edema. +2 DTR.

NEUROLOGICAL: Gross nonfocal. Denies HA, visual disturbances

Skin: Warm and dry without any rash. Neg CVA tenderness.

Fetus: Bimanual exam presents as approximately 9 wks gestation. FHTs 150s-160s. No fetal movement. US performed by MSV CNM- est gest age 9w2d. EDD 11/8/2015.

Urinalysis: neg protein, neg glucose

Assessment (A)

30 yo G1P0 IUP 9w2d weeks by early U/S.

Mild Nausea of pregnancy.

Family history of diabetes

Plan (P)

Diagnostics

– New OB Labs – T&S, CBC, G/C, RPR, Rubella, HBsAg, HIV, urine culture, HgbA1C

– Pap smear at age 21 yo per ACOG guidelines

– Fetal Genetic Screening – after counseling regarding options, pt has declined genetic screening (NT, 1st-trimester screen, NIPT)

– Cystic Fibrosis Screen

Treatment

– Daily PNV with folic acid

– Offer TDAP between 24-36 wks, offered flu vaccine when available.

– Continue exercise as tolerated; walking, yoga, swimming, light weight-bearing

– Adequate rest & hydration

Education:

-Nausea and vomiting: Small, frequent meals, crackers & ginger ale, ginger, Sea-bands (acupressure), Vit b6 & Unisom

-Exercise- counseled regarding the importance of exercise, and safe fitness level

-Counseled regarding nutrition: The patient will attempt to include lean protein, dairy, and vegetables in her diet.

-Weight gain: 25-35 lbs, varied, healthy diet with protein, fruit & veggies.

-TDAP & Flu vaccination recommendations

-Avoidance of Cat litter, gardening with gloves.

-Prenatal care schedule

-When to call the office, the emergency line number.

-Follow-up: RTO in 4 weeks &/or PRN

Example: OB Labor Progress Note

S: Patient c/o intermittent, abdominal cramping. Rating pain 5/10 and managing pain well with nitrous oxide.

O: VSS, FHR baseline 135, + accelerations, intermittent late and variable decelerations, moderate variability.

Ctx: q 2-4mins, MVUs 156-217 per IUPC; AROM for clear fluid with IUPC placement;

vertex; SVE 4/60/-3

A/P: G1P0 IUP @ 38w3d

IOL for Oligohydramnios

Increase oxytocin per protocol

Category II tracing- Continuous electronic fetal monitoring, consider amnioinfusion if decelerations worsen

GBS Positive- PCN per protocol

Pain: Epidural PRN, the patient would prefer to decline pain medication at this time other than nitrous oxide.

Reassess in 2 hours or PRN- provide labor support and position changes;

Clear liquid diet r/t Cat II tracing

OB Birth or Delivery Note

The patient was found to be completely dilated at 2119 and spontaneously bearing down at the peak of each contraction. After effectively pushing, the patient delivered a viable female infant over intact perineum at 2123. The anterior shoulder delivered easily, and the postpartum oxytocin bolus initiated. The cord was clamped x2 and cut after cessation of pulsation by the FOB. Apgars 8,9.

The placenta delivered spontaneously with gentle cord traction at 2132 and appeared to be intact upon visual inspection. The perineum was inspected and found to have a second-degree laceration repaired with 3-0 vicryl in the usual fashion. EBL 350 ml, fundus u/2, and firm. Mom and baby were left in stable condition, in skin to skin, attempting to breastfeed.

OB Postpartum SOAP note

S: Pt denies complaints. A moderate amount of lochia, no clots, voiding well, ambulating PRN, + flatus, no BM yet, denies N/V, breastfeeding without difficulty. Denies pain except intermittent cramping with breastfeeding that she rates a 3/10 and states is manageable.

Vital signs T and Tmax, P RR, BP (include ranges)

Lungs- CTAB

CV-RRR

ABD- Fundus firm, midline, u/2, nontender

laceration- clean, dry, minimal edema

Ext- +1 pitting edema, +2 DTRs, neg calf pain

A:

24 year old now G2P2022, s/p NSVD doing well PPD#2

Prenatal labs: Rubella immune, Rh positive.

Breastfeeding

Pain well controlled

P:

Routine postpartum care

Rx: Ibuprofen 600mg PO q 6 hours; Tylenol 1000mg PO q 6 hours PRN breakthrough pain

Colace daily

Micronor for contraception to start at 3 weeks

Lactation consult prior to Discharge

Discharge home

Follow up in 2 weeks for postpartum depression clinic and 6 weeks for Postpartum visit with Dr. _____ or CNM ______

SOAP Notes in the Medical Field

The SOAP note is an essential method of documentation in the medical field. It’s imperative that every student learn the basics of writing a SOAP note to become a health care provider like a physician or an Advanced Practice Nurse.

As a Certified Nurse-Midwife, I use notes like these in everyday life. I am grateful that I’ve gotten them down to a science!

These are just some examples of how to write a SOAP note with obstetric cases that one may encounter throughout your career.

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