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No history of abnormal pap smears, her last pap smear was ***. ... {***Document if procedure required single-tooth tenaculum, os finders, was without difficulty}.


Samples of SOAP Notes. Template for Episodic Visit. S: Chief complaint (CC): It is often ... Breast Exam Documentation. Normal Exam: Size (if remarkable).


I'm not aware of a CPT code for separately obtaining a Pap smear. ... In your example, to make the nurse's visit a separately identifiable service, the chart would ....


A: Please reference attached sample codes; reference Value Set Directory for ... Chronic Problem List with documentation of Pap smear with or without HPV,.


The pap smear is done as part of a well woman exam and screening for ... in the cervical os, in a full clockwise direction, then place the sample directly into ...


Pap smear (prn)- ecto and endo cervix. Herpes- at site of ... Biopsy is ok if healing is documented prior to enrollment. ○ The need for a pap smear in 6 months is not considered ...


Gynecological history: Last pap smear 7/20/2011. Last MMG ... Brush was used to remove cervical cell sample from squamocolumnar junction. Another sample ...


Jul 9, 2009 ... Situation: Well woman encounter and the only documentation that a pap ... exam) , but there is nothing that states a sample was taken for a PAP.


Gonorrhea and Chlamydia testing (if ages 25 or younger and sexually active) – may consider urine testing if not needing a pap smear/pelvic for other reasons.


Cervical gonorrhea & Chlamydia culture: - Pap smear: normal. - PPD: not done. - Sickle prep: not done. - HIV test: NR. - Glucose test: Denies having it done.