Download General Ob.Gyn. Epic Smart Phrases

Common smart phrases/clinic templates for general
ob/gyn (created by faculty physicians)
Topic
Page No.
Annual Exam
2-8
Colposcopy
9-11
Cryotherapy
12-13
Endometrial Biopsy
14-15
Implanon/Nexplanon placement
16-19
Implanon Removal
20-21
IUD placement
22-23
IUD Check
24-25
LEEP
26-29
LEEP POSTOP
30
Pap/cervical dysplasia f/u
31
Pre op for C-section
32-34
2 week c-section check
35
Post op general
36-37
Postpartum
38-40
Pre op H&P
42-44
Vaginitis
45
1
Annual Exam
Dumermuth
CC: Annual Gynecologic Examination
HPI: @NAME@ is a @AGE@ G***P*** who presents for annual gynecologic
examination. She has the following concerns: ***
Health Maintenance: She exercises ***days per week with ***. She wears her seatbelt
routinely. She *** perform*** monthly self breast exams. She *** had her cholesterol
checked ***. Her @PAPDATE@ She feels safe at home.
@MEDICALHX@
@SURGICALHX@
Past OB/Gyn History:
@OB@, menstrual cycles every *** days, with *** days of *** bleeding. Denies any
history of sexually transmitted infection. No history of abnormal pap smears, her last
pap smear was ***.
@FAMHX@
Social History:
@SOC@
@ALLERGY@
@MEDSCURRENT@
Review of Systems:
A complete review of systems was performed and was negative, except as listed.
***
Physical Exam:
@VS@
GEN: The patient was alert and oriented x3, pleasant well-appearing female in no acute
distress.
HEENT: Unremarkable, no anterior or posterior lymphadenopathy, no thyromegaly
CV: RRR, no murmurs
RESP: Clear to auscultation bilaterally
BREAST: Symmetric breasts with no palpable breast masses or obvious breast lesions.
She has no retractions or nipple discharge. She has no axillary abnormalities or palpable
masses. Self breast exam is taught.
ABD: Soft, nontender, nondistended, normoactive bowel sounds, ***
EXT: WWP, nontender, no edema
BACK: No CVA tenderness, no tenderness to palpation along spine
PELVIC: Normal appearing external female genitalia, normal vaginal epithelium, no
abnormal discharge. Normal appearing cervix. Bimanual: No CMT, *** week uterus,
nontender. No palpable adnexal masses. Rectovaginal exam was ***.
Assessment & Plan: @NAME@ is a @AGE@ @GP@ with ***.
1. Pap: The patient's @PAPDATE@ She is due for a repeat pap ***.
2
2. I discussed regular exercise, self breast exams, routine seat belt use. She is due for
***.
Anderson
CHIEF COMPLAINT:
1. Annual examination.
2. ***
HISTORY OF PRESENT ILLNESS:
@FNAME@ is a @AGE@ female who presents today for a routine annual examination
and discussion of the above. @GP@ ***
PAST MEDICAL HISTORY:
Current Health Link data were reviewed with the patient/updated as necessary.
PAST SURGICAL HISTORY:
Current Health Link data were reviewed with the patient/updated as necessary.
FAMILY HISTORY:
Current Health Link data were reviewed with the patient/updated as necessary.
Breast cancer: {Yes/No:60}. Ovarian cancer: {Yes/No:60}. Uterine cancer:
{Yes/No:60}. Colon cancer: {Yes/No:60}. Osteoporosis: { Yes/No:60}.
OB/GYN HISTORY:
@OB@
@LMP@.
Last Pap: @LPAP@
History of abnormal Paps, sexually transmitted infections, or pelvic inflammatory
disease: {Yes/No:60}.
SOCIAL HISTORY:
She is {marital status:62} and works ***.
Exercise regularly: {Yes/No:60}.
Tobacco: {TOBACCO USE:13621}
Alcohol: {ALCOHOL USE:13625}
Caffeine: {CAFFEINE USE:13623}
Wears seat belt on a regular basis: {Yes/No:60}.
Feels safe in her current environment: {Yes/No:60}.
***
MEDICATIONS:
@cmeds@
ALLERGIES:
Current Health Link data were reviewed with the patient/updated as necessary.
SCREENING:
Last Papanicolaou test: @LPAP@.
Last cholesterol: @LCHOL@.
3
Last tetanus: @LTETANUS@.
Last mammogram: @LMAMMO@.
Regular self-breast exam: {Yes/No:60}.
Calcium intake: {Yes/No:60}.
***
REVIEW OF SYSTEMS:
Please see history of the present illness for pertinent positives.
{NEGATIVE ROS COMPLETE FEMALE:10171}
PHYSICAL EXAMINATION:
VITAL SIGNS: @VS@
GENERAL: She is {GENERAL APPEARANCE:5021}.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Mucous
membranes are moist. Oropharynx is clear without erythema.
NECK: No preauricular, submandibular, or supraclavicular lymphadenopathy. No
thyromegaly.
SPINE: Straight. There is no costovertebral angle tenderness.
SKIN: No atypical nevi or rash.
EXTREMITIES: Without cords, edema, or rash.
CARDIOVASCULAR EXAM: Regular rate and rhythm, normal S1 and S2, and no
murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, {FLAT/OBESE:602}, nontender, and nondistended. No
hepatosplenomegaly. No rebound or guarding. Groin is without lymphadenopathy.
NEUROLOGIC EXAM: Alert and oriented times 3. No focal deficits.
BREAST EXAMINATION: Bilaterally symmetrical breasts. There is no axillary
lymphadenopathy. No mass, discharge, or dimpling.
GYNECOLOGIC EXAM: {PELVIC EXAM:709} {*** Insert your normal pelvic exam}
Stool today is Hemoccult negative.
ASSESSMENT:
Normal gynecologic exam.
Routine GYN exam per the Wisconsin Well-Women Program.
See Health Link diagnoses.
PLAN:
1.
2.
3.
4.
She was counseled regarding her findings.
She will be notified with the results of her Pap smear.
STD testing was offered and {DONE:12093}.
Screening: We discussed breast self-examination, and a shower card was given.
We discussed calcium and vitamin D intake, and a handout was given. She will
have a fasting cholesterol panel for screening. {HEALTH MAINTENANCE:5237}
{SCREENING MEDICARE:11683}
5. Followup: I have recommended annual examinations or sooner with concerns.
Her questions were answered.
4
Bennett
CHIEF COMPLAINT:
3. Annual examination.
4. ***
HISTORY OF PRESENT ILLNESS:
@FNAME@ is a @AGE@ female who presents today for a routine annual examination
and discussion of the above. @GP@ ***
OB/GYN HISTORY:
@OB@
@LMP@.
History of abnormal Paps:{Yes/No:60}
Sexually transmitted infections, or pelvic inflammatory disease: {Yes/No:60}.
Sexually Active:{YES/CAP NO:18859}
Contraception:{contraception:11438}
SCREENING:
Last Papanicolaou test: @PAPDATE@
Last cholesterol: @RESULAST(chol:1,trig:1,hdl:1,ldl:1)@
Last tetanus: Tetanus vaccination status reviewed: {TETANUS STATUS:5746::"Tetanus
re-vaccination not indicated"}.
Last mammogram: @MAMDATE@
Regular self-breast exam: {Yes/No:60}.
Calcium/Vitamin D intake: {Yes/No:60}.
Last Colonoscopy: @COLODATE@
Last Bone Density scan: @BONEDATE@
Past Medical, Surgical and Family History:
Current Health Link data were reviewed with the patient/updated as necessary.
Family hx of breast cancer, ovarian cancer, colon cancer? {Yes/No:60}
Family hx of thromboembolic event, clotting disorder? {Yes/No:60}
Family hx of CVD? {Yes/No:60}
Family hx of diabetes? {Yes/No:60}
SOCIAL HISTORY:
She is {marital status:62} and works ***.
Exercise regularly: {Yes/No:60}.
Tobacco: {TOBACCO USE:13621}
Alcohol: {ALCOHOL USE:13625}
5
Wears seat belt on a regular basis: {Yes/No:60}.
Bike Helmet: {YES/CAP NO:18859}
Feels safe in her current environment: {Yes/No:60}.
MEDICATIONS:
@cmeds@
ALLERGIES:
Current Health Link data were reviewed with the patient/updated as necessary.
REVIEW OF SYSTEMS:
Please see history of the present illness for pertinent positives.
{NEGATIVE ROS COMPLETE FEMALE:10171}
PHYSICAL EXAMINATION:
VITAL SIGNS: @VS@
GENERAL: She is {GENERAL APPEARANCE:5021}.
HEENT: Sclerae are anicteric. Mucous membranes are moist. Oropharynx is clear
without erythema.
NECK: No preauricular, submandibular, or supraclavicular lymphadenopathy. No
thyromegaly.
SKIN: No atypical nevi or rash.
EXTREMITIES: Without edema, or rash.
CARDIOVASCULAR EXAM: Regular rate and rhythm, normal S1 and S2,
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, {FLAT/OBESE:602}, nontender, and nondistended. No
hepatosplenomegaly. No rebound or guarding. Groin is without lymphadenopathy.
NEUROLOGIC EXAM: Alert and oriented times 3. No focal deficits.
BREAST EXAMINATION: Bilaterally symmetrical breasts. There is no axillary
lymphadenopathy. No mass, discharge, or dimpling.
GYNECOLOGIC EXAM: {PELVIC EXAM:709}
***Stool today is Hemoccult negative. ***
ASSESSMENT:
Normal gynecologic exam.
***
PLAN:
6. She will be notified with the results of her Pap smear.
7. STD testing was offered and {DONE:12093}.
8. Screening: We discussed calcium and vitamin D intake. ***Screening
mammogram ordered *** She will have a fasting cholesterol panel for screening.
***Immunizations given*** {HEALTH MAINTENANCE:5237} {SCREENING
MEDICARE:11683}
9. Followup: I have recommended ***annual examinations or sooner with
concerns. Her questions were answered.
6
Bradley
CC: Annual exam
HPI: @NAME@ is a @AGE@ G***P*** who presents for ***
Past Medical History:
@MEDICALHX@
Past Surgical History:
@SURGICALHX@
Past OB/Gyn History:
@OB@, menstrual cycles every *** days, with *** days of *** bleeding. Denies any
history of sexually transmitted infection. No history of abnormal pap smears. Her last
pap smear was ***.
Family History:
@FAMHX@
Social History:
@SOC@
Review of Systems:
Skin: No rashes or discolorations of any concern.
RESP: Denies SOB, no cough.
CV: Denies chest pain or palpitations.
Breasts: Denies masses, pain and nipple discharge.
GI: Denies abdominal pain. Denies changes in bowel habits.
GU: Denies dysuria, frequency, incontinence and hematuria.
Genitalia: Denies abnormal vaginal discharge.
Physical Exam:
@VS@
GEN: The patient was alert and oriented x3, pleasant well-appearing female in no acute
distress.
HEENT: Unremarkable, no anterior or posterior lymphadenopathy, no thyromegaly
CV: RRR, no murmurs
BREASTS: Breasts: Symmetric. No dominant, discrete, fixed or suspicious masses are
noted. No skin or nipple changes. No palpable axillary nodes.
RESP: Clear to auscultation bilaterally
ABD: Soft, nontender, nondistended, no masses or organomegaly
BACK: No CVA tenderness, no tenderness to palpation along spine
7
PELVIC: Normal appearing external female genitalia, normal vaginal epithelium, no
abnormal discharge. Normal appearing cervix. Uterus is smooth, mobile and, nontender.
No palpable adnexal masses. No anoperineal lesions. Rectovaginal exam was ***. A
thin prep pap smear was obtained.
SKIN: No concerning lesions
EXTREMITIES: No edema
Assessment & Plan:
1. Routine annual exam.
We discussed ACOG guidelines for pap smear screening frequency. ***
We discussed healthy diet, exercise, self breast awareness.
RTC one year or earlier PRN.
2.
8
COLPOSCOPY
Anderson
Colposcopy Exam
CHIEF COMPLAINT: @CHIEFCOMPLAINTN@
HISTORY OF PRESENT ILLNESS: The patient is a @AGE@ female who ***
@@CMED@
@ALGENC@
PHYSICAL EXAMINATION:
Vital Signs: @V@
General: Well-developed, well-nourished, @AGE@ female in no acute distress.
Pelvic Exam: External genitalia reveal normal BUS and vulva. No lesions,
whitened epithelium, or erythema. Vagina is pink, moist, and rugous without
lesions. No abnormal discharge. No blood. Cervix is {CERVIX EXAM:11354}.
Parametrium is clear. Gross naked eye description: ***.
IMPRESSION:
@DIAG@
PLAN:
1. We discussed abnormal Pap smears, commonality of HPV and possible role in
cervical dysplasia and cervical cancer. We discussed HPV vaccine options
currently FDA indicated for ages 11-25.
2. We discussed colposcopic exam for assessment, procedure, risks, and
benefits. Patient was given handouts. The patient desires to proceed with
colposcopy.
PROCEDURE NOTE: Colposcopic examination of the vulva, vagina, and
cervix was performed, including application of acetic acid, and is diagramed
on the colposcopy form in chart. Findings: ***. Biopsy/ies done:
{YES/NO:12193}. Pap done: {YES/NO:12193}
3. Disposition will be pending pathology, but we discussed probable observation if
mild dysplasia versus age-specific observation or treatment if moderate or
severe dysplasia.
4. ***
Dumermuth
@AGE@ year old female presents for colposcopy referred by ***.
Indications:
Pap smear *** showed: {PAP SMEAR DIAGNOSES:726::"normal"}. Prior pap(s) showed
{PAP SMEAR DIAGNOSES:726::"normal"}.
@LMP@.
9
Contraception: {contraception:11438}
Number current sexual partners: ***
Number of partners in lifetime: ***
High risk partner: {Yes/No:10029::"No."}
History of STD: {Yes/No:10029::"No."}
Future fertility desired: {Yes/No:10029::"No."}
Prior cervical/vaginal findings: {COLPOSCOPY ASSESSMENT:733}.
Prior cervical treatment: {COLPOSCOPY TREATMENT RECOMMENDATIONS:727}.
Symptoms/History:
Abnormal vaginal discharge: {Yes/No:10029::"No."}
HIV: {Yes/No:10029::"No."}
Pregnant: {Yes/No:10029::"No."}
Postmenopausal: {Yes/No:10029::"No."}
DES Exposure: {Yes/No:10029::"No."}
Intermenstrual bleeding: {Yes/No:10029::"No."}
Postcoital bleeding: {Yes/No:10029::"No."}
Immunosuppressed: {Yes/No:10029::"No."}
Bleeding Problems (non-gynecological): {Yes/No:10029::"No."}
Smoking: {YES/NO:64}
NSAID current use: ***
Other serious chronic illnesses: ***
Procedure for colposcopy and biopsy has been explained to the patient including
indication for colposcopy and alternatives as well as risks and potential complications.
{CONSENT TYPE:10035::"Verbal"} informed consent was obtained.
PROCEDURE:
The speculum was placed in vagina and excellent visualization of cervix was achieved.
The greenfield filter was used. *** atypical vasculature was noted. Cervix was swabbed
x3 with acetic acid solution.
FINDINGS:
Cervix: {COLPOSCOPY CERVIX FINDINGS:728}; {COLPOSCOPY CERVIX
PROCEDURE:729}.
Vaginal inspection: {COLPOSCOPY VAGINAL EXAM:730}.
Vulvar colposcopy: {COLPOSCOPY VULVAR EXAM:731}.
Procedure Summary: {COLPOSCOPY SUMMARY:732}.
ASSESSMENT:
{COLPOSCOPY ASSESSMENT:733}.
PLAN:
1. All specimens were labeled and sent to Pathology, we will base further treatment on
pathology findings. We will call patient with biopsy results.
2. Treatment options briefly discussed with patient. All questions answered.
3. Postbiopsy instructions were given to patient. The patient was asked to call with any
questions or concerns.
10
Miller
REFERRING PROVIDER: @pcp@
HISTORY OF PRESENT ILLNESS: A @age@, {RACE:8101} is here for colposcopy for
a Pap smear showing {reason for colposcopy:15840}.
Prior history of abnormal Pap: {Yes/No:60}.
Prior colposcopy: {Yes/No:60}.
Contraception: {contraception:15149}.
Nursing note is reviewed.
Discussed with patient continuum of abnormalities of the cervix, including atypical
squamous cells of undetermined significance, low-grade dysplasia, and high-grade
dysplasia. Discussed that in general either atypical squamous cells of undetermined
significance or low-grade dysplasia is followed closely. Discussed that some patients
with low-grade dysplasia progress, but some patients with low-grade dysplasia regress
to normal, and that we usually do give patients time to see if they will revert to normal
with observation. Discussed that if low grade is confirmed, I would recommend a repeat
Pap smear in 4 months and a repeat colposcopy if abnormal Pap persists at 1 year.
I did discuss that high-grade dysplasia is treated, and treatment would consist of either
cryocautery of the cervix or loop electrical excision procedure (LEEP) cervical cone
biopsy. The idea behind both treatments is that they get rid of the abnormal surface
cells on the cervix, and that the surface cells are replaced with healthy normal cells.
Discussed that the purpose of the colposcopy is to ascertain the exact level of her
dysplasia. Discussed that in all likelihood we will be recommending a cervical biopsy.
Patient was in agreement. Consent was obtained. Patient was given brochures
outlining both of these procedures.
PROCEDURE NOTE: Acetic acid was applied. On colposcopic examination, there was
white epithelium {with/without:10391} mosaicism at ***. There {WAS/WAS NOT:9033}
punctation. Biopsy was taken at the *** o'clock area. Monsel solution was applied to the
base of the biopsy site for hemostasis. {COLPOSCOPY SUMMARY:11499}
IMPRESSION: Abnormal Pap.
PLAN: We will plan to notify the patient of biopsy results when available. ***
11
Cryotherapy
Dumermuth
@AGE@ female present for cryotherapy. Her colposcopy on *** had a biopsy showing
*** with negative ECC. Based on her biopsy results I recommended proceeding with
either an excisional procedure in the form of a LEEP or cryotherapy. Both options were
discussed in detail. Since her last visit, she has no new complaints or concerns and no
changes in her medical history. The patient desires cryotherapy.
The cryotherapy procedure was discussed with the patient in detail. The risks, benefits,
alternatives and indications for the procedure were reviewed in detail. The patient
understands the implications of cryotherapy procedure on future fertility and pregnancy.
She understands that she could have some cervical stenosis making obtaining
pregnancy difficulty in the future. She could also develop pyometria with associated PID.
She also understands the small risk of preterm delivery after cryotherapy. The patient
understands the risk of infection, the risk of bleeding and the risk of injury to other
organs during this procedure. All the patient's questions were answered regarding the
procedure prior to proceeding. Verbal and written consent was obtained.
The patient was placed in dorsal lithotomy. Her external female genitalia appeared within
normal limits. An insulated speculum was inserted. The vaginal epithelium was
visualized and appeared to be within normal limits. Her cervix is easily visualized. A
colposcope was used to further visualize her cervix. The entire extent of the lesion was
identified. A paracervical block was then performed with 1% lidocaine at the 4 and 8
o'clock positions around the cervix. Cryotherapy was then performed with *** minute
freeze, *** minute thraw and *** minute freeze, covering the entire transformation zone.
This was done in an uncomplicated fashion. Excellent hemostasis was noted.
The patient tolerated the procedure well. There were no complications with the
procedure. The patient was doing well post procedure. She was not lightheaded or dizzy
and was asymptomatic. Her cervix was hemostatic.
ASSESSMENT AND PLAN: Ms @NAME@ is a @AGE@ female with CIN-*** now
status post cryotherapy procedure performed today. The patient will return to the clinic
in 2 weeks' time to evaluate her cervix status post her cryotherapy. All the patient's
questions were answered in detail in the clinic today. Her followup plan and further
treatment will be discussed when she returns for her post procedure visit.
Bennett
Cryotherapy Procedure Note
Diagnosis: ***
@NAME@ @AGE@ @GP@ who presents for cryotherapy of her cervix for *** cervical
dysplasia. Risks, benefits and alternatives were discussed including persistent disease
and need for retreatment, cervical stenosis, injury to vaginal tissues. She consented to
procedure. A plastic speculum was placed in the vaginal and the cervix was visualized,
appropriate probe selected. The probe was applied to the cervix and freezing employed
for 3 minutes, defrost for 1 minute, then another 3 minutes of freezing. She tolerated the
procedure well.
12
Follow up care and expectations reviewed, including refraining from intercourse and
using only tampons for the next 2 weeks.
She will return for a follow up pap at 6 month intervals for the next year, then yearly for
the next 20 years.
13
Endometrial biopsy
Anderson
We discussed possible causes of bleeding, as above. We discussed possible
sonohysterogram. We discussed role of endometrial biopsy for diagnostic purposes and
reviewed procedure, risks, and benefits. The patient desired to proceed with
endometrial biopsy. Pap smear was {DONE:12093}.
PROCEDURE NOTE: Vacurette endometrial biopsy was performed using aseptic
technique with iodine preparation. {***Document if procedure required single-tooth
tenaculum, os finders, was without difficulty}
The uterus was sounded to a length of *** cm. Adequate sampling was obtained with
minimal blood loss. The patient tolerated the procedure well. Disposition will be
pending pathology.
Dumermuth
After discussion with the patient regarding her abnormal uterine bleeding I recommended that
the patient proceed with an endometrial biopsy for further diagnosis. The risks, benefits,
alternatives, and indications for an endometrial biopsy were discussed with the patient in detail.
She understood the risks including infection, bleeding, cervical laceration and uterine
perforation with injury to other organs like her bowel and bladder. The patient was agreeable
to proceed with an endometrial biopsy and verbal consent was obtained. At this point a
bimanual exam was performed, which revealed an approximately ***-week size uterus that was
*** position with no palpable adnexal masses, cervical motion tenderness, or abnormalities. On
speculum exam, the patient no abnormalities in her vaginal epithelium. Her cervix was easily
visualized and thought to be within normal limits. The cervix and vagina was then cleansed with
Betadine x 3. A single-tooth tenaculum was placed on the anterior lip of the cervix and an
endometrial biopsy was performed without difficulty. Her uterus sounded to *** cm. Adequate
tissue appeared to be obtained. The patient tolerated the biopsy without difficulty. No
complications occurred during the biopsy. The tenaculum was removed from the anterior lip of
the cervix. Hemostasis was noted.
Bradley
Procedure Note: Endometrial biopsy
After discussion with the patient regarding her abnormal uterine bleeding I
recommended that she proceed with an endometrial biopsy for further diagnosis. The
risks, benefits, alternatives, and indications for an endometrial biopsy were discussed
with the patient in detail. She understood the risks including infection, bleeding, cervical
laceration and uterine perforation. Verbal consent was obtained.
14
A bimanual exam was performed, which revealed an approximately ***-week size ***
anteverted uterus with no palpable adnexal masses, cervical motion tenderness, or
abnormalities. On speculum exam, there were no abnormalities in her vaginal
epithelium. Her cervix was easily visualized and thought to be within normal limits. The
cervix and vagina was then cleansed with Betadine x 3. A single-tooth tenaculum was
placed on the anterior lip of the cervix. Her uterus sounded to *** cm. The biopsy pipelle
was advanced and the specimen obtained in the usual fashion. An adequate amount
tissue appeared to be obtained. The patient tolerated the procedure well without
difficulty. No complications occurred. The tenaculum was removed from the anterior lip
of the cervix. Good hemostasis was noted.
15
Implanon/Nexplanon placement
Dumermuth
Today she was given information about Implanon, was allowed to review that information
and had no questions about Implanon placement. Implanon was reviewed with the
patient in detail, including other options for contraception. The patient was offered other
options including Depo-Provera which she declined. The patient understands that
Implanon is also a progesterone only therapy, and she could potentially have similar side
effects to Depo-Provera. The patient understands that with Implanon, often patients
have irregular and unpredictable vaginal bleeding. The patient understood this and
desired to proceed. The placement of the Implanon was reviewed with the patient in
detail including risks of nerve injury, infection, bleeding and injury to other muscles or
tendons. The patient was agreeable to proceed with placement. All of her questions
were answered. The patient understood that the Implanon is good for 3 years and needs
to be removed at the end of that time. Informed consent was obtained, both verbally and
written.
The patient is healthy and has no contraindications to Implanon use. Urine pregnancy
test was performed today and was negative.
The patient was placed on the examination table, and her left arm was placed lateral to
her body above her head in position for Implanon placement. The site, approximately 8
cm above the medial epicondyle of the humerus, was identified and marked with a pen.
A guiding mark was marked 4 cm medial to that. The area was then cleaned with an
antiseptic solution with Betadine swabs x 3. A 1% lidocaine was injected just under the
skin along the entire track of the planned Implanon insertion. The Implanon applicator
was removed from the blister pack in a sterile fashion. The Implanon rod was seen as a
white cylinder inside the top of the needle. This was then tapped back into place to
ensure that the Implanon was behind the tip of the needle. Countertraction was applied
on the skin and the tip of the needle was inserted at approximately a 20 degree angle
just below the level of the skin. The needle was then advanced in horizontal position
placing the needle in the subdermal connective tissue. The seal was broken on the
obturator. The obturator was rotated 90 degrees, and the cannula was slid back towards
the fixed obturator. The tip of the Implanon needle was examined, and the grooved tip
was seen indicating appropriate placement and deployment of the Implanon device. The
patient's arm was palpated, and the full-length of the Implanon device could be palpable.
The patient was then allowed to palpate the 4-cm long rod, and she confirmed its
placement. A small amount of bleeding was noted from the insertion site. Pressure was
held on this area and hemostasis was achieved. A small bandage was placed and a
compression dressing was applied.
The patient tolerated the placement of the Implanon without difficulty. She was given the
Implanon card and the dates to have her Implanon removed and the time frame for
effective contraception with the Implanon. The patient was given precautions about postImplanon placement, including signs of infection or signs of bleeding. The patient was
asked to call the clinic with any questions or concerns after its placement. All the
patient's questions were answered in the clinic today.
Again, the patient underwent Implanon placement in an uncomplicated fashion and
tolerated the procedure without difficulty. She will return to the clinic in 1 year's time for
an annual exam or on a p.r.n. basis as needed.
16
Bennett
IMPLANON PROCEDURE NOTE
@NAME@ @AGE@ @GP@ presents for insertion of implanon. She had previously
used *** for contraception . She desires a long acting reliable, reversible, form of
contraception. Risk and benefits to Implanon discussed including risk of infection, pain
and bruising with insertion, the need for a procedure to remove it in 3 years and side
effects of unpredictable and irregular bleeding. Written consent was obtained.
Implanon lot # ***
She was placed in the supine position. The bicipital groove of the ***left arm was
palpated and a mark was made at 6 cm and 12 cm from the elbow over the bicipital
grove. The area was cleaned with betadine x 3. 1% lidocane was then infiltrated along
the planned track of insertion. Anesthesia was tested and was adequate. The rod was
confirmed to be in the inserter. The Implanon was then inserted using a tenting motion.
The inserter was removed and grooved tip identified. The rod was palpated in the
correct position and the patient was able to palpate the rod. The area was wrapped
tightly with a kerlex bandage.
She was instructed to wear the bandage for 24 hours, call with any signs of infection.
She was given the Implanon card and instructed to have the rod removed in 3 years.
Bradley
CC: Implanon placement
HPI: @FNAME@ presents today for Implanon placement. We discussed contraception
options at a previous visit, including alternatives such as combination estrogenprogesterone options, Depo Provera, and the IUD. She was given written information
about Implanon and has decided to proceed with placement today.
She understands that Implanon is a progesterone only therapy, and that patients often
patients have irregular and unpredictable vaginal bleeding or amenorrhea. She
understands that other side effects are possible related to systemic progesterone,
including but not limited to, headaches, breast tenderness, nausea, and irritability. The
placement procedure for Implanon was reviewed with the patient in detail including risks
of nerve injury, infection, bleeding and injury to other muscles or tendons. She
understands that the Implanon implant is good for 3 years and needs to be removed at
the end of that time. She understands that Implanon is an extremely effective option for
contraception, with failure rate of <1%. This information is reviewed today and all
questions were answered. Informed consent was obtained, both verbally and written.
The patient is healthy and has no contraindications to Implanon use. Urine pregnancy
test was performed today and was negative.
Procedure:
The patient was placed on the examination table, and her non-dominant *** arm was
placed lateral to her body above her head in position for Implanon placement. The site,
17
approximately 8 cm above the medial epicondyle of the humerus, was identified and
marked with a pen. A guiding mark was marked 4 cm proximal to that. The area was
then cleaned with an antiseptic solution with Betadine swabs x 3. A 1% lidocaine was
injected just under the skin along the entire track of the planned Implanon insertion. The
Implanon applicator was removed from the blister pack in a sterile fashion. The Implanon
rod was seen as a white cylinder inside the top of the needle. This was then tapped back
into place to ensure that the Implanon was behind the tip of the needle. Countertraction
was applied on the skin and the tip of the needle was inserted at approximately a 20
degree angle just below the level of the skin. The needle was then advanced in
horizontal position placing the needle in the subdermal connective tissue. The seal was
broken on the obturator. The obturator was rotated 90 degrees, and the cannula was slid
back towards the fixed obturator. The tip of the Implanon needle was examined, and the
grooved tip was seen indicating appropriate placement and deployment of the Implanon
device. The patient's arm was palpated, and the full-length of the Implanon device could
be palpable. The patient was then allowed to palpate the 4-cm long rod, and she
confirmed its placement. A small amount of bleeding was noted from the insertion site.
Pressure was held on this area and hemostasis was achieved. A small bandage was
placed and a compression dressing was applied.
The patient tolerated the placement of the Implanon without difficulty. She was given the
Implanon card and the dates to have her Implanon removed and the time frame for
effective contraception with the Implanon. She was given precautions about postImplanon placement, including signs of infection or signs of bleeding. The patient was
asked to call the clinic with any questions or concerns after its placement. She will
return in 1 week Implanon check.
Mackey
IMPLANON PLACMENT:
Patient was consented.
Procedure was explained.
LEFT *** RIGHT arm location identified, 6-8 cm above the crease in elbow, along the crease between
biceps and triceps, on medial side of arm.
Mark placed for entry, and about 8 cm proximal to entry mark, along biceps/triceps crease.
The skin was prepped with betadine.
Area infiltrated with 1% Lidocaine, 10 ml.
Implanon stick identifed in needle.
Implanon needle introduced through skin at 20 degree angle. Once through the skin, the needle was
advanced, bevel up, under the skin, with good visualization of the bevel through the skin, confirming
subdermal advancement of the needle introducer.
After advancing the needle to the plastic handle, the obturator was released from its attachment and rotated
90 degrees. Holding the obturator still, the needle canular was withdrawn. Once the canula was withdrawn
to the end of the obturator, the entire aparatus was removed.
My medical assistant and I verified the NOTCH in the obturator.
Both the patient and I palpated the Implanon in the skin.
18
A band aid was applied to the puncture site.
A gauze sponge was used to cover the implanon.
A kerlex gauze was used to wrap the arm.
The patient was instructed NOT to lift almost anything with the Implanon arm, for 24 hours.
The patient tolerated the procedure well.
19
Implanon Removal
Dumermuth
Implanon removal discussed in detail. Risks of infection, bleeding, nerve injury all
reviewed. Patient understands risks and desires to proceed. Verbal consent obtained.
Patient is 100% sure she wants the implanon removed. All questions answered.
Procedure:
Patient placed in dorsal supine with left arm above head, elbow flexed at 90 degrees,
arm resting on examination table. Implanon identified without problems. Betadine scrub
x3. 1 ml of 1% lidocaine injected under implanon device without problems. Sterile
gloves applied. Small 0.5cm incision made at distal tip of implanon device with 11 blade
scalpel. Implanon brought to incision and grasped with a small kelly clamp. Implanon
removed intact without problems. Pressure applied to incision. Hemostasis obtained.
Steri-strips applied, followed by bandage and compression dressing. Patient tolerated
procedure well. No complications.
Assessment:
24 year old female now s/p uncomplicated implanon removal.
Plan:
1. Patient given post procedure precautions and asked to call for fever, chills, redness
or drainage from her incision, bleeding from incision. She understands she will likely
have a small bruise near site of removal and can remove bandage tomorrow and steristrips in approximately 1 week.
Mackey
=====================================================
IMPLANON REMOVAL:
The Implanon was palpated in the LEFT *** RIGHT arm.
The distal end was pushed up against the skin.
This area was infiltrated with 1% Lidocaine.
A 2 mm incision was made with an 11 blade scalpel.
Through the incision, a tiny clamp was placed, and the Implanon grasped.
The distal end of the Implanon was raised to the level of the incision. The scarred capsule around the
device was scored with the scalpel blade, exposing the white Implanon.
Using a second clamp, the Implanon was manipulated free of the capsule, and delivered out of the arm,
intact.
The Implanon was confirmed intact, and showed to the patient.
The incision was covered with a band aid, then wrapped in a curlex gauze.
She tolerated the procedure, well.
She was instructed to be cautious with her arm activity for the next 24 hours, to decrease the likelihood of
bruising.
======================================================
20
McDonald
@FNAME@ underwent placement of a contraceptive implant (Implanon) on ***.
***She states she has been bleeding most days since then. We discussed that the
bleeding has a high potential to improve, and that we could try use of low-dose,
estrogen-containing OCPs to see if her bleeding pattern improves. ***Despite this
information, she would like the implant removed. She declines prescription of an
alternate contraceptive method today, ***and is aware that her return to fertility will be
rapid after removal of the implant. We reviewed the procedure of Implanon removal
including risks, benefits, and alternatives, and consent was signed.
PROCEDURE: The patient was then placed in supine position and her ***left arm flexed
above her head to provide access to the implant site. The skin was prepped with
Betadine, and less than 1 mL of 1% lidocaine with epi was placed under the distal end of
the implant. A #11 blade was then used to incise the skin over the distal end of the
implant, and the implant grasped with a mosquito clamp. A second clamp was used to
grasp the scar tissue around the implant, and the scar capsule sharply incised. The
implant was then grasped, easily removed, and appeared fully intact. The skin was
closed with two Steri-Strips and a bandage placed, followed by a compression bandage
with gauze that she was instructed to keep in place at least 24 hours to minimize
bruising.
@FNAME@ tolerated the procedure without difficulty, and discharge instructions
including incision care were reviewed.
***
21
IUD PLACEMENT
Anderson
The patient was counseled on long-term contraceptive options. We discussed the use of
Depo-Provera injections and permanent sterilization with either tubal ligation or Essure
placement. We discussed Implanon and the ParaGard and Mirena IUDs. After
discussion of the risks and benefits of each, the patient has elected {IUD TYPE:11675}.
She understands risks of irregular bleeding or spotting, pain, cramping, expulsion,
symptomatic ovarian cyst, and ascending genital tract infection, which would be most
likely within the first 20 days post insertion. Gonorrhea and Chlamydia screening is
{PERFORMED/NOT PERF:10313}. She understands risks of uterine perforation and
possibility of {*** OTHER RISKS DISCUSSED}. She wishes to proceed with IUD
insertion. Written consent was signed.
PROCEDURE NOTE: The patient was placed in dorsosupine position in low lithotomy.
Examination under anesthesia was performed. {UTERUS EXAM:11356}. No adnexal
masses. Posterior cul-de-sac was smooth without nodularity. A sterile speculum was
inserted in the vagina. The anterior lip of the cervix was grasped with a single-tooth
tenaculum. The cervix was cleansed with Betadine. The uterus sounded to *** cm. The
{IUD TYPE:11675} IUD was placed in the normal, sterile fashion, and the strings were
trimmed to 2 cm. The tenaculum was removed, and tenaculum sites were made
hemostatic with use of a silver nitrate stick. The patient tolerated this procedure well.
Bleeding was minimal.
DISPOSITION: She will follow up in 6 weeks’ time for an intrauterine device check. She
understands that the IUD can stay in for *** years and should be replaced at that time. If
she has pain, cramping, bleeding, which is greater than 1 pad per hour, or fever, she will
return to clinic. I have counseled her to check the strings on a monthly basis. All of her
questions were answered.
Bennett
PROCEDURE NOTE: IUD INSERTION
Written consent was obtained. A speculum was placed. Cervix and vaginal walls were
prepped with Betadine. The tenaculum was applied on the anterior cervix. Uterus was
sounded to a depth of {NUMBERS - 1-10:12151} cm using a sterile uterine sound. IUD
was inserted into the uterus without difficulty. Strings were trimmed. The tenaculum
was removed. Good hemostasis was achieved with {HEMOSTASIS METHOD:11326}.
{TOLERATED PROCEDURE:10472::"The procedure was tolerated well."}
Bradley
CC: {IUD TYPE:11675} placement
SUBJECTIVE:
@NAME@ is a @AGE@ female who presents for IUD insertion. Counseling, today or
at a previous visit, was provided regarding IUD use, including alternative contraceptive
methods. Risks and benefits discussed including but not limited to spontaneous uterine
22
expulsion, uterine perforation at the time of insertion or remote from insertion. We
reviewed typical efficacy and side effects. There are no contraindications to IUD use,
and she elected to proceed with insertion.
She has a negative urine pregnancy test today.
A recent Pap smear was normal.
STD testing for gonorrhea and chlamydia was obtained ***
OBJECTIVE:
Vital Signs: @VS@
General: {general appearance:10042}.
Pelvic: {pelvic exam:11446}.
PROCEDURE NOTE: IUD INSERTION
Written consent was obtained. A speculum was placed. Cervix was prepped with
Betadine. The sharp tooth tenaculum was applied on the anterior cervix. Uterus was
sounded to a depth of {NUMBERS - 1-10:12151} cm. The IUD was inserted into the
uterus without difficulty. Strings were trimmed. The tenaculum was removed.
Hemostasis was noted. Patient was instructed on palpation of the strings.
ASSESSMENT:
IUD insertion. No contraindications identified.
PLAN:
Post IUD insertion instructions were discussed with the patient. F/U in 6-8 weeks for
IUD recheck. Patient agrees with today's plan and verbalizes understanding.
23
IUD Check
Dumermuth
Ms. @NAME@ presents for IUD string check. Since placement of her IUD she had ***
vaginal bleeding. She denies any cramping or discomfort. She has had intercourse and
did not have any problems with her IUD. Her partner was not able to feel the strings with
intercourse. She has checked the strings and is able to feel them. She denies any
fever, chills, nausea, vomiting, or other complaints.
@VS@
Gen: NAD, A&Ox3
Pelvic: Normal appearing external female genitalia, normal vaginal epithelium, no
abnormal discharge. Normal appearing cervix. IUD strings visible and 3 cm in length
similar to at the time of placement.
Assessment and Plan:
@AGE@ yo female s/p Mirena IUD placement, doing well.
1. The patient was given instructions to check her IUD strings monthly and call with any
problems or concerns. She should call for fevers, chills, abnormal vaginal discharge,
pelvic pain, or other complaints.
2. She will return for a annual exam in 1 year. All questions answered.
Bennett
Ms. @NAME@ presents for IUD string check. Since placement of her IUD she had ***
vaginal bleeding. She denies any cramping or discomfort. She has had intercourse and
did not have any problems with her IUD. Her partner was not able to feel the strings with
intercourse. She has checked the strings and is able to feel them. She denies any
fever, chills, nausea, vomiting, or other complaints.
@VS@
Gen: NAD, A&Ox3
Pelvic: Normal appearing external female genitalia, normal vaginal epithelium, no
abnormal discharge. Normal appearing cervix. IUD strings visible and 3 cm in length
similar to at the time of placement.
Assessment and Plan:
@AGE@ yo female s/p Mirena IUD placement, doing well.
1. The patient was given instructions to check her IUD strings monthly and call with any
problems or concerns. She should call for fevers, chills, abnormal vaginal discharge,
pelvic pain, or other complaints.
2. She will return for a annual exam in 1 year. All questions answered.
24
Bradley
CC: IUD check
HPI: @FNAME@ is a @AGE@ year old woman who returns today for IUD check. She
had a *** IUD placed on ***. Since the IUD was placed, *** . The strings do not interfere
with intercourse. She denies any abdominal pain, unusual vaginal discharge, fever or
chills. No dyspareunia.
Physical Exam:
Vitals: @VS@
General: Pleasant woman in no acute distress
Abdomen: Soft, non-tender, non-distended
Pelvic Exam: Normal appearing external female genitalia, normal vaginal epithelium, no
abnormal discharge. Normal appearing cervix. The IUD strings are visible. No cervical
motion tenderness.
Lower extremities: No edema
Impression: Routine IUD check. Satisfied with the *** IUD.
Plan: She will return as needed. She was reminded the IUD would need to be replaced
in *** years. She was encouraged to call with any additional questions or concerns,
otherwise follow up for routine preventative health care.
McDonald
@FNAME@ is a @AGE@ @GP@ here for an IUD check. She underwent placement
of a {IUD TYPE:11675} IUD on ***.
@LMP@. She describes her bleeding pattern as ***. She reports *** pain with her
bleeding.
@VS@
Gen: No apparent distress.
Abdomen: Soft, nontender.
Pelvic: Normal external genitalia; vulva without lesions or discharge. After placement of
the speculum, the IUD strings are easily visualized. On bimanual exam, the uterus is
nontender. and no pelvic masses are appreciated.
Assessment: @AGE@ @GP@ here for an IUD check with IUD in place.
Plan: Expectations for future menstrual patterns and possible symptoms were reviewed
with @FNAME@ today, and she will call with any further concerns.
25
LEEP
Dumermuth
@AGE@ female present for LEEP procedure. Her colposcopy on *** had a biopsy
showing ***. Based on her biopsy results I recommend proceeding with an excisional
procedure in the form of a LEEP. Since her last visit, she has no new complaints or
concerns and no changes in her medical history.
The LEEP procedure was discussed with the patient in detail. The risks, benefits,
alternatives and indications for the procedure were reviewed in detail. The patient
understands the implications of a LEEP procedure on future fertility and pregnancy. She
understands that she could have some cervical stenosis making obtaining pregnancy
difficulty in the future. She also understands the risk of preterm delivery after a LEEP
procedure with the decreased cervical stroma remaining. The patient understands the
risk of infection, the risk of bleeding and the risk of injury to other organs during this
procedure. All the patient's questions were answered regarding the procedure prior to
proceeding. Verbal consent was obtained.
The patient was placed in dorsal lithotomy. Her external female genitalia appeared within
normal limits. A speculum was inserted. The vaginal epithelium was visualized and
appeared to be within normal limits. Her cervix is easily visualized. A colposcope was
used to further visualize her cervix. Lugol solution was placed on her cervix, and the
entire extent of the lesion was identified. The patient's cervical stroma was injected with
1% lidocaine superficially circumferentially around her cervix. A LEEP was then
performed removing an approximate 3 mm depth of tissue, excising the entire
transformation zone. This was done in an uncomplicated fashion. The LEEP was
performed ***. The loop was then removed. The specimen was marked at the 12 o'clock
position. The loop was removed and ball cautery was used to cauterize the base of the
LEEP specimen and create hemostasis. Excellent hemostasis was noted. Monsel
solution was placed on the patient's cervix.
The patient tolerated the procedure well. There were no complications with the
procedure. The patient was doing well post procedure. She was not lightheaded or dizzy
and was asymptomatic. Her cervix was hemostatic.
ASSESSMENT AND PLAN: Ms @NAME@ is a @AGE@ female with CIN-*** now
status post a LEEP procedure performed today. The specimen was labeled and sent to
pathology. It was marked at the 12 o'clock position with ink. The results will be called to
the patient when they are available. The patient will return to the clinic in 2 weeks' time
to evaluate her cervix status post her LEEP procedure. All the patient's questions were
answered in detail in the clinic today. Her followup plan and further treatment will be
discussed when her pathology is available.
Anderson
CHIEF COMPLAINT: The patient presents for cervical loop excision.
26
HISTORY OF PRESENT ILLNESS: The patient is a @AGE@ female who ***
@CMED@
@ALGENC@
PHYSICAL EXAMINATION:
Vital Signs: @V@
General: Well-developed, well-nourished, @AGE@ female in no acute distress.
Pelvic Exam: External genitalia reveal normal BUS and vulva. No lesions, whitened
epithelium, or erythema. Vagina is pink, moist and rugous without lesions, whitened
epithelium, or erythema. Cervix is CERVIX EXAM:11354}. No whitened epithelium,
lesions, or abnormal discharge.
IMPRESSION:
@DIAG@
PLAN:
1. Treatment options, risks, and benefits were discussed, including option of observation
for CIN-1 and age-related recommendations for treatment of CIN-2 and CIN-3.
Treatment options of cryocautery versus LEEP cervical excision, laser, or conization
were discussed. Additional benefits of pathology for review with LEEP or cone were
discussed. ACOG handouts were given for review. Possible risks of infection,
bleeding, cervical scarring, or weakening that could adversely affect future pregnancies
with possible increased risk of cervical incompetence, the potential failure rates, and
need for continued surveillance postprocedure were discussed. All questions were
answered. The patient desires to proceed with cervical LEEP excision.
2. Colposcopic examination was performed using acetic acid application followed by Lugol
solution. Findings were ***.
PROCEDURE NOTE: A submucosal ectocervical injection of 1% lidocaine was used for
anesthesia. The *** cervical loop was used to excise the transformation zone. Additional
excisions: {YES/NO:12193}. Endocervical curettage was performed. Hemostasis was
obtained with the use of ball cautery and application of Monsel solution. Estimated blood
loss: {estimated blood loss:15522}. The patient tolerated the procedure well and was
given written instructions on postoperative care. She will be seen in 2 weeks for followup,
sooner prn.
Bennett
@AGE@ female present for LEEP procedure. Her colposcopy on *** had a biopsy
showing ***. Based on her biopsy results I recommend proceeding with an excisional
procedure in the form of a LEEP. Since her last visit, she has no new complaints or
concerns and no changes in her medical history.
The LEEP procedure was discussed with the patient in detail. The risks, benefits,
alternatives and indications for the procedure were reviewed in detail. The patient
understands the implications of a LEEP procedure on future fertility and pregnancy. She
27
understands that she could have some cervical stenosis making obtaining pregnancy
difficulty in the future. She also understands the risk of preterm delivery after a LEEP
procedure with the decreased cervical stroma remaining. The patient understands the
risk of infection, the risk of bleeding and the risk of injury to other organs during this
procedure. All the patient's questions were answered regarding the procedure prior to
proceeding. Verbal consent was obtained.
The patient was placed in dorsal lithotomy. Her external female genitalia appeared within
normal limits. A speculum was inserted. The vaginal epithelium was visualized and
appeared to be within normal limits. Her cervix is easily visualized. A colposcope was
used to further visualize her cervix. Lugol solution was placed on her cervix, and the
entire extent of the lesion was identified. The patient's cervical stroma was injected with
1% lidocaine superficially circumferentially around her cervix. A LEEP was then
performed removing an approximate 3 mm depth of tissue, excising the entire
transformation zone. This was done in an uncomplicated fashion. The LEEP was
performed ***. The loop was then removed. The specimen was marked at the 12 o'clock
position. The loop was removed and ball cautery was used to cauterize the base of the
LEEP specimen and create hemostasis. Excellent hemostasis was noted. Monsel
solution was placed on the patient's cervix.
The patient tolerated the procedure well. There were no complications with the
procedure. The patient was doing well post procedure. She was not lightheaded or dizzy
and was asymptomatic. Her cervix was hemostatic.
ASSESSMENT AND PLAN: Ms @NAME@ is a @AGE@ female with CIN-*** now
status post a LEEP procedure performed today. The specimen was labeled and sent to
pathology. It was marked at the 12 o'clock position with ink. The results will be called to
the patient when they are available. The patient will return to the clinic in 2 weeks' time
to evaluate her cervix status post her LEEP procedure. All the patient's questions were
answered in detail in the clinic today. Her followup plan and further treatment will be
discussed when her pathology is available.
Mackey
=========================================================
Physical Exam @VS@ ***
=========================================================
LEEP procedure
vulva – no lesions or lacerations
vagina – no lesions or lacerations, well estrogenized, good support
cervix – normal appearing, mobile, non tender
Insulated speculum was placed.
The transformation zone was visualized using acetic acid and Lugol's strong iodine.
Intracervical block was achieved with 1% lidocain, with epinephrine.
Bovie was set on 75/75.
LEEP was achieved with a ***
Yellow 10 x 10 mm
Green 15 x 12 mm
White 20 x 12 mm
Blue 20 x 15 mm
28
*** Utah Surgical LOOP.
An endocerical "button" was excised separately, using the yellow 10 x 10 mm loop. ***
The LEEP bed was cauterized for hemostasis and appropriate tissue destruction.
The patient tolerated the procedure quite well.
=========================================================
McDonald
A @age@ female presents for LEEP.
INDICATIONS:
*** on biopsy *** date, ***negative/benign ECC.
Procedure for colposcopy and LEEP has been explained to the patient, including
indication for treatment and alternatives, as well as risks and potential complications.
Written (see scan) informed consent was obtained.
PROCEDURE:
The speculum was placed in vagina, and excellent visualization of cervix was achieved.
Cervix was swabbed x 3 with acetic acid solution.
FINDINGS:
Cervix: Visible lesion(s) at {NUMBERS 1-12:10} o'clock; SCJ was visualized; *** mL of
1% lidocaine was injected for a cervical block. Lugol's solution was applied. A *** cm
LEEP wire was used at 70/70 on cut for excision of entire SCJ to a depth of 0.5 cm. Ball
cautery was used at the base, and Monsel's applied for excellent hemostasis.
Vaginal Inspection: Normal without visible lesions.
Vulvar Colposcopy: Vulvar colposcopy was not performed.
Procedure Summary: Patient tolerated procedure well. Colposcopy satisfactory.
ASSESSMENT:
CIN {NUMBERS 1-12:10}; LEEP performed.
PLAN:
Post-procedure instructions were given to patient, and she will return in 2 weeks to
discuss pathology results and for post-LEEP exam.
29
LEEP POSTOP
Dumermuth
HPI: Ms. @NAME@ presents for postoperative visit after LEEP for CIN ***. Since
LEEP she has had *** vaginal bleeding. She denies any cramping or discomfort. She
denies any fever, chills, nausea, vomiting, or other complaints.
@VS@
Gen: NAD, A&Ox3
Pelvic: Normal appearing external female genitalia, normal vaginal epithelium, no
abnormal discharge. Cervix healing well after LEEP.
Pathology: ***
Assessment and Plan:
@AGE@ yo female s/p LEEP for CIN ***, doing well.
1. The pathology results were discussed with the patient. She should return to the clinic
in *** months for ***.
2. She should call for fevers, chills, abnormal vaginal discharge, pelvic pain, or other
complaints. All questions answered.
30
Pap/cervical dysplasia follow up
Dumermuth
Patient here for 6 month follow-up pap. She had a pap revealing *** in *** and
colposcopy with ***. She denies any complaints today.
@VS@
Gen: NAD, A&Ox 3
Pelvic: Normal appearing external female genitalia, normal vaginal epithelium, no
abnormal discharge. Normal appearing cervix.
A/P @AGE@ female with *** at her last colposcopy, here for repeat pap.
1. Pap: Will contact patient with results when they are available. If patient has 2 normal
pap smears in a row she can return to routine screening. If abnormal she will need to
return for colposcopy. All questions answered.
Bradley
CC: Pap smear
HPI: @FNAME@ presents today for a follow up pap test. Last pap was done *** and
showed ***. She had colposcopy done on ***. Biopsies from this showed ***. ECC
showed ***.
@FNAME@ has been doing well and has no concerns today. She is using *** for
contraception. She {IS/IS NOT:9024} a smoker.
Physical Exam:
Vitals: @VS@
General: Pleasant young woman in no acute distress
Pelvic exam: Vulva is without lesions nor discharge. GU: Vagina and vulva are normal;
no discharge is noted. Cervix appears ***.
Impression: CIN ***, here for follow up pap.
Plan: Pap smear is done today. We will notify @FNAME@ of this result when it
becomes available. If negative, RTC in *** {MONTHS (4,6,12):11300} for ***.
***Smoking cessation recommended.
31
Preop for C-section
Bradley
CC: Preoperative visit
HPI: @FNAME@ is a @AGE@ @GP@ who presents today for preoperative visit prior
to c-section scheduled on ***date for ***indication. She will be *** weeks at the time of
her scheduled c-section. She {does/not:10487} desire tubal sterilization at the time of
her surgery. Her pregnancy has been {COMPLICATED:9078}.
@PMH@
@PSH@
@OB@
@SOC@
PHYSICAL EXAM:
@VS@
GEN: The patient was alert and oriented x3, pleasant well-appearing female in no acute
distress.
CV: RRR, no murmurs
RESP: Clear to auscultation bilaterally
ABD: Soft, gravid, nontender
EXT: WWP, nontender, no edema
BACK: No CVA tenderness, no tenderness to palpation along spine
PELVIC: Deferred today.
Fetal heart tones: Normal by doppler today.
Prenatal labs:
@BLOODTYPE@
@BRIEFLAB(rh:1)@
@BRIEFLAB(rubl:1)@
@BRIEFLAB(hiv:1)@
@BRIEFLAB(hbsag:1)@
@BRIEFLAB(rpr:1)@
@BRIEFLAB(glu1:1)@
Last CBC Test
@RESULAST(rbccount,wbcb,hgb,hct,plt,mcv:)@
Impression/Plan: @FNAME@ is a @AGE@ @GP@ scheduled for c-section on
***date. We reviewed risks of surgery, including bleeding which may require transfusion,
infection, damage to internal organs, and abnormal placentation in future pregnancies.
***We have previously reviewed risks and benefits of proceeding with repeat cesarean
section versus TOLAC, and she desires to proceed with repeat c-section.
32
***OR
***We have previously discussed the risks and benefits of primary c-section for
***indication, and she desires to proceed with c-section as scheduled.
All questions are answered. Verbal and written consent are obtained today.
@ME@ @TD@ @NOW@
Sabo
Preoperative History and Physical
Procedure: Repeat/Primary Cesarean Delivery
DOS: ***
Location: Meriter/St. Mary's
@NAME@ is a @AGE@ @GP@ who presents for preoperative history and physical.
@NAME@ has ***
Current Pregnancy
@problem list@
Labs: @bloodtype@ @GBS@
Past OB/Gyn History:
Regular monthly menstrual cycles with no intermenstrual or post coital bleeding. No
history of sexually transmitted infection. No history of abnormal pap smears, her last
pap smear was ***.
@MEDICALHX@
@SURGICALHX@
@ALLERGY@
@CMEDS@
@FAMHX@
Social History:
@SOC@
Review of Systems:
A review of systems was negative except as per HPI.
Physical Exam:
@VS@
GEN: The patient was alert and oriented x3, pleasant well-appearing female in no acute
distress.
33
HEENT: Unremarkable, no anterior or posterior lymphadenopathy, no thyromegaly
CV: RRR, no murmurs
RESP: Clear to auscultation bilaterally
BREAST: Deferred
ABD: Soft, nontender, nondistended. ***
EXT: WWP, nontender, no edema
PELVIC: Deferred today.
Assessment: @NAME@ is a @AGE@ @GP@ with ***, she is scheduled for a *** on
***.
Plan:
***
34
2 week c-section check
Dumermuth
Subjective:
Patient here for incision check s/p cesarean delivery on *** for ***. Since her cesarean
she has been doing well. Her mood is good. She is *** feeding. She has no breast
concerns. She denies fevers, chills, nausea, emesis, redness or drainage from incision.
She has minimal vaginal bleeding. She denies any problems with urination or bowel
movements. She is using *** on an occasional basis for pain.
Objective:
@VS@
Gen: NAD, A&O x3
Abd: Soft, nontender, nondistended
Inc: Healing well, no erythema, no induration
Ext: WWP, nontender
Assessment and plan:
@AGE@ yo female 2 weeks s/p cesarean delivery for ***, doing well.
1. Incision: ***
2. Overall doing well since delivery. Continue with activity and lifting restrictions until 6
weeks post-op. RTC 3-4 weeks for postpartum visit. Patient to call with any concerns.
McDonald
SUBJECTIVE:
@FNAME@ returns to clinic today for follow-up after ***primary or repeat C/S performed
***.
***history
Op report reviewed- procedure was uncomplicated LTCS with average blood loss.
@FNAME@ denies any specific concerns today. She is *** bottlefeeding or
breastfeeding without difficulty. She has minimal incisional pain and is using Ibuprofen
as needed.
OBJECTIVE:
On exam, her incision is well-healed with no induration, erythema, or discharge. Incision
is nontender to palpation.
IMPRESSION & PLAN:
@AGE@ @GP@ recovering well {NUMBERS - 0-6:12148} weeks postop from
uncomplicated ***PLTCS or RLTCS.
Continued instructions for activity and healing were reviewed, and she will return in
{NUMBERS - 0-6:12148} weeks for a postpartum exam.
35
Postop general
Dumermuth
Patient here for post operative check s/p *** on *** for ***. Since her surgery she has
been doing well. She denies fevers, chills, nausea, emesis, redness or drainage from
incision. She has *** vaginal bleeding. She denies any problems with urination or
bowel movements. She is using *** on an occasional basis for pain.
@VS@
Gen: NAD, A&O x3
Abd: Soft, nontender, nondistended
Inc: Healing well, no erythema, no induration
Ext: WWP, nontender
A/P: @AGE@ yo female 2 weeks s/p *** for ***, doing well.
1. Incision:
2. Overall doing well since surgery. Continue with activity and lifting restrictions until 6
weeks post-op. RTC in 1 year for an annual exam and prn. Patient to call with any
concerns.
KC Mackey, MD, OBGYN
Contact me with questions:
608/575-4519
kcmackey@ wisc.edu
[]
[]
[]
[]
Patient: @NAME@
DOB: @DOB@
Visit Date: @FDATE@
UW West Clinic - OBGYN
=========================================================
involved providers – @PCP@
age - @AGE@
=====================================================
cc: Post operative visit: Type of surgery ***
HPI:
Surgery was on: ***
Indication for surgery: ***
Operative reprot and path information is attached. ***
Post operative course has been unremarkable.
She reports normal bowel and bladder function.
She has minimal pain, and is no longer taking narcotic pain medication.
She reports minimal vaginal discharge.
Today we reviewed the surgery, the pathoolgoy results, and what she can expect during her recovery.
36
=====================================================
Ogden
Reason for visit: Post op
Surgery: ***
Date of surgery: ***
Complications: ***
Surgical findings: ***
Pathology: ***
@NAME@ is a @AGE@ female here today for her postop visit. She had an
uncomplicated post op course. She was discharged to home on POD# ***. Her activity
level has returned to normal. She is no longer taking pain medications. She returned to
work ***. She denies problems with vaginal discharge. Her bowel and bladder are
functioning normally.
@VS@
In general, this is a well-appearing female in no acute distress. She is able to move
about the exam room without difficulty. Abdominal exam reveals a soft, nontender.
Incisions are well-healed without erythema or exudates. External genitalia are normal.
No excoriations or ulcerations. Normal vaginal ruggation and estrogenation.
Cervix is normal in appearance. Bimanual exam reveals a normally sized mobile uterus
which is nontender and there are no appreciable adnexal masses. No tenderness.
Vaginal cuff is normal in appearance. Some suture material is visible. No unusual
discharge. Bimanual exam reveals a surgically absent uterus. Cuff is nontender and
there is no induration.
Impression: Normal post op exam.
Surgical findings and pathology were reviewed with the patient today and any questions
answered. She will return to @PCP@ for her routine care. She was instructed to call
with any questions or concerns.
37
POSTPARTUM
Dumermuth
SUBJECTIVE:
@NAME@ is a @AGE@ @SEX@ who presents for postpartum exam. Since delivery
she has been doing well. Her vaginal bleeding stopped *** weeks ago. She has *** had
intercourse. She denies any perineal complaints. Her mood is ***. She is *** feeding.
She has no breast complaints. She desires *** for postpartum birth control.
I have fully reviewed the prenatal and intrapartum course. The delivery was on
@OBBABYDOB@ at @OBBABYGA@ Outcome: @OBBABYDELTYPE@. Sex:
@OBBABYGENDER@, Wt: @OBBABYWT@
OBJECTIVE:
@VS@
GEN: Appears well, no acute distress
HEENT: No lymphadenopathy or thyromegaly.
CV: RRR, no murmurs.
RESP: Lungs clear to auscultation bilaterally
ABD: soft, nontender, nondistended, normoactive bowel sounds
PELVIC: Normal appearing external female genitalia, no lesions, well healed perineum,
normal vaginal epithelium, normal appearing cervix
BIMANUAL EXAM: No cervical motion tenderness, uterus approximately *** weeks, no
palpable adnexal masses.
EXT: no edema
ASSESSMENT:
@NAME@ is a @AGE@ @GP@ @SEX@ now *** weeks postpartum, doing well.
PLAN:
1. Contraception: Patient desires ***, risks and benefits discussed with patient.
2. Pap smear: @PAPDATE@. ***.
3. RTC for annual exams and p.r.n.
4. Postpartum depression signs and symptoms discussed with patient, patient
encouraged to call the clinic with any concerns.
5. All questions answered.
McDonald
@FNAME@ presents today for a postpartum exam.
38
This is a @AGE@ @GP@ who delivered by @OBBABYDELTYPE@ at ***Meriter or St.
Mary's Hospital on @OBBABYDOB@***.
She is currently breastfeeding ***and bottle-feeding her @OBBABYGENDER@,
@OBBABYNAME@.
Her depression scale score was reviewed and is within normal limits. ***
She denies any concerns regarding ***perineal pain, problems with bowel movements or
bladder function, or persistent bleeding.
See vitals above
Exam:
General: No acute distress.
Breasts: ***Deferred or no evidence of infection, masses, nipple problems, or
engorgement.
Abdomen: Soft, nontender; no palpable masses; ***well-healed low transverse incision
present.
Pelvic: Normal external female genitalia visualized.
Inspection of the labia, urethra, vestibule, vagina, and cervix reveals no lesions or
discharge. Pap using Thin Prep method is performed.
***The perineum appears well-healed and is nontender.
Bimanual exam confirms a normal-sized uterus in midline with no pelvic or adnexal
tenderness.
@FNAME@ is a @AGE@ @GP@ recovering well following @OBBABYDELTYPE@ on
@OBBABYDOB@.
1. Pap performed today, monthly self-breast exam reviewed and encouraged, and
breastfeeding advice reviewed.
2. Contraceptive options and risk for pregnancy while breastfeeding discussed today.
***
She will return to clinic in one year for routine annual exam.
Miller
{INTERPRETER OFFERED:11685}.
SUBJECTIVE: Patient presents for a postpartum visit. @GP@ She is status post {OB
DELIVERY METHOD:9039} on ***. Delivery was {DELIVERY COMPLICATEDUNCOMPLICATED:11820}. The baby was a {sex:14957} whose name is ***. Patient is
{FEEDING:11152} and {FEEDING ASSESSMENT:10764}. She plans to use
{contraception:11438} for contraception.
Concerns: {None/list:10440}.
Pregnancy: {pregnancy complicated/uncomplicated:15606}. Recovery was uneventful.
Postpartum depression symptoms: {yes/no:60}.
Vaginal bleeding: {yes/no:60}. She {has/has not:9025} had a menses.
Wound concerns: {yes/no:60}.
Nursing note is reviewed.
39
OBJECTIVE:
Vital Signs: @VS@
{PHYSICAL EXAM OPTIONS:11828}
Abdomen: Incision is {HEALING STATUS UROGYN:12206}.
Pelvic Exam : Normal female external genitalia. Vagina with rugae. Cervix is without
overt lesions. Uterus is normal in size. No adnexal masses are palpable.
IMPRESSION: Normal postpartum exam.
PLAN: {POSTPARTUM PLAN:738}
Contraception: {CONTRACEPTION:15149}. She has no contraindications to
contraception as planned.
{CONTRACEPTION BENEFITS/RISKS/SIDE EFFECTS:11678}
40
PREOP H&P
McDonald
GYN Preoperative H&P
CC: ***
HPI: @NAME@ is a @AGE@ @GP@ who presents complaining of ***
@MEDICALHX@
@SURGICALHX@
Past OB/Gyn History:
Past Oncology History:
@ALLERGY@
@MED@
Review of Systems:
General: {general:10386}
Skin: {ROS-Skin:10385::"Negative."}
ENT: {ROS-ENT:10399::"Negative."}
Hematologic/Lymphatic/Immunologic: {ROS-Hem/Lym:10396::"Negative."}
Eyes: {eyes:10384::"Negative."}
Respiratory: {ROS-Resp:10387::"Negative."}
Cardiovascular: {ROS-CV:10388::"Negative."}
Gastrointestinal: {ROS-GI:10389::"Negative."}
Genitourinary: {GU:10392::"Negative"}
Musculoskeletal: {ROS-MSK:10393::"Negative."}
Neurologic: {ROS-Neuro:10395::"Negative."}
Endocrine: {ROS-Endo:10397::"Negative."}
Psychiatric: {ROS-Psych:10398::"Negative."}
Physical Exam:
{physical exam:13108}
Laboratory Data:
Last CBC Test
@RESULAST(rbccount,wbcb,hgb,hct,plat,mcv)@
Last BMP Test
@RESULAST(NA,K,CL,CO2,BUN,Cret,GLU,CA)@
Imaging: ***
Assessment & Plan: @AGE@ @GP@ with ***.
The treatment plan is to proceed with ***. The risks, benefits, and alternatives of surgery
were discussed with the patient in detail, including bleeding, infection, and damage to
surrounding organs such as bowel and/or bladder. Written consent was obtained. We
will also obtain a preoperative CBC, type & screen, CXR, and EKG.
41
The patient was given handouts with routine preoperative information and was provided
with a list of medications, herbs, and vitamins to avoid prior to surgery. See orders for
prescriptions provided to be started perioperatively as directed. An EKG {HAS/HAS
NOT:14934} been ordered per anesthesia guidelines. Recommended preoperative labs
have been ordered, please see orders for details. Other instructions given: ***. She was
asked to contact us if there are any questions, concerns, or problems prior to surgery. All
of her questions were answered.
Dumermuth
Preoperative History and Physical
Procedure: ***
DOS: ***
Location: ***
@NAME@ is a @AGE@ G***P*** who presents for preoperative history and physical.
Please see my previous clinic notes for full details. Briefly, @NAME@ has ***
@MEDICALHX@
@SURGICALHX@
Past OB/Gyn History:
Menstrual cycles every *** days, with *** days of *** bleeding. Denies any history of
sexually transmitted infection. No history of abnormal pap smears, her last pap smear
was ***.
@FAMHX@
Social History:
@SOC@
@ALLERGY@
@MEDSCURRENT@
Review of Systems:
A complete review of systems was performed and was negative, except as listed.
***
Physical Exam:
@VS@
GEN: The patient was alert and oriented x3, pleasant well-appearing female in no acute
distress.
HEENT: Unremarkable, no anterior or posterior lymphadenopathy, no thyromegaly
CV: RRR, no murmurs
RESP: Clear to auscultation bilaterally
BREAST: Deferred
ABD: Soft, nontender, nondistended, normoactive bowel sounds, ***
EXT: WWP, nontender, no edema
BACK: No CVA tenderness, no tenderness to palpation along spine
42
PELVIC: Deferred today.
Assessment & Plan: @NAME@ is a @AGE@ @GP@ with ***, she is planning a *** on
***.
***
Bradley
CC: Preoperative visit
HPI: @FNAME@ is a @AGE@ woman who presents today for preoperative visit prior to
*** scheduled on ***date for ***.
@PMH@
@PSH@
@OB@
@SOC@
PHYSICAL EXAM:
@VS@
GEN: The patient was alert and oriented x3, pleasant well-appearing female in no acute
distress.
HEENT: Unremarkable, no anterior or posterior lymphadenopathy, no thyromegaly
CV: RRR, no murmurs
RESP: Clear to auscultation bilaterally
ABD: Obese, nontender, nondistended, normoactive bowel sounds
EXT: WWP, nontender, no edema
BACK: No CVA tenderness, no tenderness to palpation along spine
PELVIC: Deferred today.
Impression:
Plan: We will obtain *** for preoperative evaluation. She will schedule a postoperative
visit with me 2-4 weeks after her procedure. She was given *** for use after her
procedure. All questions answered.
Ogden
Reason for visit: Preop
Indication for surgery:
Proposed surgery:
Date of surgery:
Location of surgery:
Preop testing required:
History:
43
@PMH@
@PSH@
@MED@
@ALLERGY@
Objective:
@VS@
In general, pt is a well-appearing female who appears her stated age. She is in no acute
distress. She asks and answers questions appropriately. She makes good eye contact.
Heart has regular rate and rhythm. No murmurs appreciated. Lungs were clear to
ascultation bilaterally. Pelvic exam deferred to OR.
Imaging studies:
Endometrial biopsy result:
Impression:
Plan:
***insert risks of planned procedures
The consent form was reviewed in detail with the patient today. She had the opportunity
to ask questions and all of her questions were answered to her satisfaction. She will call
with any new questions or concerns.
44
Vaginitis
Dumermuth
Ms. @NAME@ is a @AGE@ yo female who presents for ***. Her symptoms started
***. She complains of ***. She denies hematuria, dysuria, constipation, diarrhea, fevers,
chills, nausea or emesis.
@VS@
Gen: NAD, A&O x3
Pelvic: Normal appearing external female genitalia, normal vaginal epithelium, ***.
Normal appearing cervix. Bimanual: No CMT, *** week uterus, nontender. No palpable
adnexal masses. Rectovaginal exam was ***. Wet prep was obtained. Cultures for
gonorrhea and chlamydia collected.
Wet Prep: pH ***, Clue cells ***, Hyphae ***, Trichomonas ***
A/P: @AGE@ yo female with ***
1.
45
MISCELLANEOUS
St. Mary’s tubal letter
Bennett
St. Mary's Medical Staff Office/Tubal Ligation Committee
700 S Park St.
Madison WI 53715
Dear Tubal Ligation Committee:
@id@, @GP@, who will be scheduled for a repeat cesarean section at St. Mary's
Hospital in ***. She desires to have a tubal ligation at the time of her cesarean delivery.
The patient has a history of *** other cesarean section and *** vaginal delivery. With the
increased risk of each cesarean section, I ask that you approve her request to have a
tubal ligation at the time of her surgery.
Letter to dentist
Bradley
To Whom It May Concern:
This is to confirm that @NAME@ is a patient of UW Health.
She is currently pregnant with @EDD@. She may receive any indicated dental
procedures during her pregnancy, including fillings and tooth extractions. It is safe to use
local anesthetic in pregnancy as needed during these procedures. She may have x-rays
performed with shielding of her abdomen. Please avoid flouroquinolone antibiotics.
Other antibiotics including penicillin-based drugs are safe in pregnancy.
Please contact our office with any questions at 608-828-7610.
Sincerely,
46