PROBLEM-FOCUSED SOAP NOTE 23-year-old female in clinic

PROBLEM-FOCUSED SOAP NOTE 23-year-old female in clinic complaining of irregular menses LMP August 20, 2022 Menses prior was February 2022 Weight gain of 40lbs in the past 6 mos Occasional cigarette smoker, an occasional marijuana smoker 1 New male partner in the past month Subjective Data HPI Med History – make up answers for her Social Hx Family Hx 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 Include DDX Plan Include medication (if appropriate) Include education, teaching, follow up, and referral (if appropriate) SCIENCE HEALTH SCIENCE NURSING NURS 6053

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