Women health soap note
Nursing is a field that requires adequate and effective documentation. Soap note is a method of documenting patient information when diagnosing to determine the best kind of medication (Podder, Lew, Ghassemzadeh, 2020). The following is a soap note for a woman who visited the hospital.
Subjective (S)
Data identification:
Name: Jane Smith
Age: 31
Gender: Female
Marital Status: Single
Chief complain: The patient states that she needed a birth control checkup and pap test.
History of illness: The patient explained that she had her last birth control when she was 6 years and she has been dating for five years. Her last pap years ago indicated a normal condition.
Past medical history (PMH):
Immunization: Up to date immunization.
Previous screening: she had a normal pap condition in 2016. Her mother is a cancer survivor who was diagnosed at the age of 35.
Pains: No.
Objective data (O):
Constitutional: BP-111/68, weight- 75 lbs, Height: 5.5m,
Eyes: normal sclerae white, extraocular movements
Ear: normal external appearance, no swelling.
Mouth: Mucous membranes, 3 missing teeth.
Throat: No inflammation, exudate, Tonsils
Nose: No mucous, Nares patients.
General palpation: No subcutaneous tissue masses present.
Genitourinary: No distention noted.
Assessment (A):
- Family planning
- Pap smear
V26.08 Advice on contraceptive management.
The patient requested an advice on her contraceptives and advise on what to do when she misses medication.
The patient needed advice on her pap condition. She is sexually active and hence pap smears are recommended regularly.
Plan (P):
- The pap smear test was done with ease. The samples are in the laboratory and the results are pending. Patient will receive the result through mail at home.
- Encourage the patient to maintain only one sex partner to avoid vaginal infections while under the Tri Spritec birth control.
Medication profile: Tri Sprintec
Indication: Pregnancy prevention.
Dosage: One tablet per day.
Follow up: One year.
Patient education:
- Do not smoke while taking the dose.
- Do not miss any medication and any missing should be rectified soonest possible.
- The use of birth control does not prevent against the transmission of HIV/AIDS.
- Pap test should be done on regular basis.
References
Podder, V., Lew, V., Ghassemzadeh, S. (2020). SOAP Notes. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/
Patient encounters for family planning and contraceptives is a common occurrence in women’s health, thus it is important as APRNs to be able to effectively manage these visits and document findings appropriately.
What were the findings noted from the patient for the ROS?
Also, what were the detailed objective findings from the physical exam?
Lastly, what exactly is family planning and PAP smear? Please include detailed descriptions of both.
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