Comprehensive Women’s Health History and Physical Template
Comprehensive Women’s Health History and Physical Template
SOAP Notes 1
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive SOAP note is to be written using the attached template below.
(see attached)
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| S = | Subjective data: Patient’s Chief Complaint (CC). |
| O = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| A = | Assessment: Diagnosis of the patient’s condition. Include differential diagnosis. |
| P = | Plan: Treatment, diagnostic testing, and follow up |
Submission Instructions:
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
- Complete and submit the assignment using the appropriate template in MS Word by 11:59 PM ET Sunday.
Comprehensive Women’s Health History and Physical Template
Encounter date:
Patient Initials: Gender: Age: Race/Ethnicity:
Reason for Seeking Health Care
History of Present Illness (HPI)
Allergies (Drug/Food/Latex/Environmental/Herbal)
Current Perception of Health
Current Medications (including over the counter)
Menstrual History
Age at Menarche
Last menstrual period
Menstrual Pattern
Cycle Length
Duration of Flow
Amount of Flow
Bleeding Pattern
Break through Bleeding
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Gynecologic History
History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)
Previous GYN surgery (may include that in surgical history)
History of infertility
History of diethylstilbestrol (DES) use by patient’s mother
Last pap smear, history of abnormal pap
Pre-menopause/menopause
Vasomotor symptoms
Hormone Replacement Therapy
Sexual and Contraceptive History
Current method of contraception
Sexually active
Number of sexual partners
New partners in the 3-6 months
Condom use
History of sexual abuse
History of sexually transmitted infections (STIs)
Obstetric History (including complications)
Past Medical History (PMH)
Major/Chronic Illnesses
Trauma/Injury
Hospitalizations
Past Surgical History
Family Medical History
Social History
Living condition
Marital status
Education
Employment
Occupation
Social supports
Habits (smoking, alcohol use and illicit drugs use)
Health Maintenance
Age-appropriate health promotion/maintenance and screening history
Immunization history
Review of Systems (ROS)
General
Dermatology
HEENT
Neck
Pulmonary System
Cardiovascular System (CVS)
Breast
Gastrointestinal (GI) System
Genitourinary (GU) System
Female Genitalia
Musculoskeletal System
Neurological System.
Endocrine
Psychologic
Hematologic/Lymphatic
Physical Examination
Vital Signs
Blood Pressure (BP: Temperature Heart Rate (HR) Respiratory Rate (RR)
Height Weight Body Mass Index (BMI) Pain
General Appearance
Dermatology
HEENT
Neck
Pulmonary System
Cardiovascular System (CVS)
Breast
Gastrointestinal (GI) System
Genitourinary (GU) System
Female Genitalia
Musculoskeletal System
Neurological System.
Endocrine
Psychologic
Hematologic/Lymphatic
| Significant Data/Contributing Dx/Labs/Misc
|
Assessment
Differential Diagnoses (3 minimum)
Primary Diagnoses
Plan (For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit)
Diagnoses
Laboratory/Diagnostic Studies
Therapeutic (Non-pharmacological interventions)
Pharmacological Therapy
Patient Education/Anticipatory Guidance
Referrals
Follow up
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Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________
Signature (with appropriate credentials): __________________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
