MINI SOAP NOTE PROMPT
A 41-year-old female is in the clinic to follow up on Pap results and she also reports a new palpable mass in her breast. It is approximately 1×1 cm mobile, tender, lump in her left breast that seems more noticeable just prior to and during menses. She uses a Copper T IUD x 5 years w/o problems with contraception. Her LMP was 3 weeks ago. She is G 2 P 2-both uncomplicated normal spontaneous vaginal deliveries.
She’s been divorced x 6 years. Smokes tobacco 5 cigs/day since age 20, drinks 1-2 glasses of wine most nights, no drugs. Regular diet. VS WNL BMI 28.2
– Recent Pap result is ASCUS w/ +HPV
To be completed in below format – make up information not given. complete in its entirety
Subjective Data
– HPI- complete for the patient matching her chief complaint.
– Med History – make up answers for her
– Think risk factors? Ask and make up answers for what risk factors could she have
– Use OLDCART
– Include ROS
Objective Data
– Include vital signs
– Include point of care testing (POCT) (if appropriate)
– Include an appropriate exam
Assessment
– Include ICD 10 code
Plan
Include medication (if appropriate)
– Are there medications that may help someone with HPV?
– Include education, teaching, follow up, and referral (if appropriate)
– What is the plan for her?
– USE ASCCP and USPSTF guidelines, please. Please reference.
– You can also include what would be her follow up with her result was ASCUS