RUNNING HEAD: OBSTETRIC ISSUE - SOAP NOTE WEEK 11 1
Obstetric Issue – Soap Note Week 11
Natalie D. Robinson BSN, RN
Walden University
NURS 6551, Primary Care of Women
April 23, 2019
This study source was downloaded by 100000859819779 from CourseHero.com on 01-15-2023 10:33:33 GMT -06:00
https://www.coursehero.com/file/44386188/WK11ROBINSONNSOAPdocx/
, OBSTETRIC ISSUE – SOAP NOTE WEEK 11 2
Obstetric Issue - SOAP Note Week 11
Patient Information:
Initials: O.N. Age: 34 Sex: Female
S.
CC: Abnormal vaginal bleeding for one week.
HPI: O.N. is a 34-year-old Caucasian female who is G 2 P 0 1 0 1 and currently at 15
weeks and 3 days gestation. She is seen in the office today for abnormal vaginal bleeding
for one week. She describes the vaginal bleeding as mild and moderate and as bright red
blood without any clots. The patient denies any associated factors that may have led to
the vaginal bleeding such as sexual intercourse/penetration, excessive physical activity, or
trauma/injury to the pelvis or vagina. The vaginal bleeding is not associated with any pain
and her uterus and abdomen remained soft at all times.
Current Medications: Prenatal Vitamins PO daily
Immunization History: all childhood immunizations are up to date. Patient received
two HPV vaccinations. Positive rubella titer screened at first prenatal visit. Received
Influenza immunization in October 2018.
Allergies: No known drug allergies and no food or environmental allergies.
PMHx: none
PSHx: Laparoscopic appendectomy at 28 years old
SOCHx: single mother of one child (5 years old) who lives with her mother in an
apartment. She is currently working full time at grocery store. She is covered by her
occupational health insurance.
Sexual/Reproductive History: G 2 P 0 1 0 1
STI’s: none
Contraception: none
Last Pap: at first prenatal visit on 3/1/2019
Menarche: Age 12
Rh-Factor: positive
Personal/Social History:
Tobacco Use: No
Smokeless Tobacco: No
Passive Smoke: No
Drug Use: No
HIV risk: No
Caffeine use: Occasional
This study source was downloaded by 100000859819779 from CourseHero.com on 01-15-2023 10:33:33 GMT -06:00
https://www.coursehero.com/file/44386188/WK11ROBINSONNSOAPdocx/
Obstetric Issue – Soap Note Week 11
Natalie D. Robinson BSN, RN
Walden University
NURS 6551, Primary Care of Women
April 23, 2019
This study source was downloaded by 100000859819779 from CourseHero.com on 01-15-2023 10:33:33 GMT -06:00
https://www.coursehero.com/file/44386188/WK11ROBINSONNSOAPdocx/
, OBSTETRIC ISSUE – SOAP NOTE WEEK 11 2
Obstetric Issue - SOAP Note Week 11
Patient Information:
Initials: O.N. Age: 34 Sex: Female
S.
CC: Abnormal vaginal bleeding for one week.
HPI: O.N. is a 34-year-old Caucasian female who is G 2 P 0 1 0 1 and currently at 15
weeks and 3 days gestation. She is seen in the office today for abnormal vaginal bleeding
for one week. She describes the vaginal bleeding as mild and moderate and as bright red
blood without any clots. The patient denies any associated factors that may have led to
the vaginal bleeding such as sexual intercourse/penetration, excessive physical activity, or
trauma/injury to the pelvis or vagina. The vaginal bleeding is not associated with any pain
and her uterus and abdomen remained soft at all times.
Current Medications: Prenatal Vitamins PO daily
Immunization History: all childhood immunizations are up to date. Patient received
two HPV vaccinations. Positive rubella titer screened at first prenatal visit. Received
Influenza immunization in October 2018.
Allergies: No known drug allergies and no food or environmental allergies.
PMHx: none
PSHx: Laparoscopic appendectomy at 28 years old
SOCHx: single mother of one child (5 years old) who lives with her mother in an
apartment. She is currently working full time at grocery store. She is covered by her
occupational health insurance.
Sexual/Reproductive History: G 2 P 0 1 0 1
STI’s: none
Contraception: none
Last Pap: at first prenatal visit on 3/1/2019
Menarche: Age 12
Rh-Factor: positive
Personal/Social History:
Tobacco Use: No
Smokeless Tobacco: No
Passive Smoke: No
Drug Use: No
HIV risk: No
Caffeine use: Occasional
This study source was downloaded by 100000859819779 from CourseHero.com on 01-15-2023 10:33:33 GMT -06:00
https://www.coursehero.com/file/44386188/WK11ROBINSONNSOAPdocx/
