Nurse Practitioner Template
Transgender HRT SOAP
A professional Nurse Practitioner template for healthcare professionals.
About this template
The Transgender HRT SOAP template is a comprehensive documentation tool designed for Nurse Practitioners managing transgender hormone therapy. This template facilitates detailed recording of patient history, subjective and objective findings, and care plans specific to hormone replacement therapy. It includes sections for presenting history, subjective complaints, medical history, objective exam findings, assessment, and care plans. This template is particularly useful for clinicians in transgender health care, ensuring thorough and consistent documentation. It supports the inclusion of ICD codes, such as F64.9 for Gender Dysphoria, and is optimized for use with the Heidi AI medical scribe.
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PRESENTING HISTORY/CC:
Patient presents to clinic today for transgender hormone therapy management. The patient is a 28-year-old individual assigned female at birth, identifying as male, and uses he/him pronouns. He has been on hormone therapy for 2 years. The patient realized he was transgender at the age of 16. Recent lab findings indicate stable testosterone levels. He has a supportive social network, including family and friends. The patient is interested in full gender transition results. He works as a software engineer and has been seeing a therapist for the past year to support his transition.
SUBJECTIVE FINDINGS:
- The patient requests a review of his current hormone therapy regimen.
- Reports occasional mood swings, which have been present for the past few months.
- Mood swings are alleviated by regular exercise and meditation.
- No previous episodes of similar symptoms.
- Mood swings have a mild impact on daily activities, including work.
- No associated symptoms reported.
- Recently moved to a new city for work.
MED HISTORY AND/OR PRIOR HRT:
- Previous hormone therapy began 2 years ago at another clinic.
- Past medical history includes anxiety, managed with therapy.
- No significant family history relevant to the visit.
- Immunizations are up to date.
OBJECTIVE FINDINGS:
EXAM FINDINGS:
General: No acute distress. Calm and cooperative.
HEENT: NCAT, Vision/Hearing grossly intact, Swallows without difficulty. No speech impairments.
Cardiac: Skin appears well perfused, and is stated as warm and dry. No stated palpitations or CP.
Pulm: No obvious externally audible wheezing. Breathing is even and unlabored on room air. No cyanosis noted. No reported SOB.
Neuro: A&O x 4. GCS = 15. No reported dizziness or numbness/tingling. Moves all extremities spontaneously.
Psych: Appropriate affect. No obvious hallucinations/delusions or stated SI/HI.
GI: No obvious visible masses. No c/o N/V/D or abd pain.
Integumentary: No visible rashes or jaundice.
Genito-Urinary: No stated discomfort.
ASSESSMENT & DIAGNOSIS CODES:
- F64.9 Gender Dysphoria
PLAN FOR CARE & FOLLOW UP:
- Continue current hormone therapy regimen.
- Schedule follow-up labs in 3 months to monitor hormone levels.
- Continue therapy sessions for mental health support.
- Next follow-up appointment scheduled for 02/01/2025.
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