SOAP NOTE – 39-year-old female 29 weeks

SOAP NOTE – 39-year-old female 29 weeks GA – G2P0A1 – office visit date is 5/22/22 – Pt in the clinic for follow up 1-hour GTT result., 1 hr gtt result failed ( tested last week on 5/15/22 at 28 weeks) – Weight gain of 25lbs since initial OB visit Subjective Data – Include HPI Include her non-pregnant medical health history and her previous pregnancy & delivery history – Include ROS Objective Data – Include vital signs (Blood Pressure 118/80, HR 76, Pulse Ox 100, temp 97.8) – Include point of care testing (POCT)- what do expect to see here? – Include any labs and diagnostic testing done in the clinic – Include an appropriate exam Assessment – Include ICD 10 code – Include DDX Plan – Include follow up plan/ referral – Include medication (if appropriate) – Include education, teaching, follow up, and referral (if appropriate)

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