SOAP Note Template Initials : BF Age: 58 Gender: M Height Weight BP HR RR Temp SPO2 Pain Allergies 5’11 97kg 146/ 90 104 19 36.7C 98% Medication: Codiene( Nausea/Vomitting) Food: NFA Environment: NA History of Present Illness (HPI) Chief Complaint (CC) I have been having some troubling chest pain in my chest now and then for the past month. CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom O nset Early this month. L ocation Middle chest. D uration Last a minute or more. C haracteristics Tight and uncomfortable in the middle of chest that does not radiate. A ggravating Factors Yard work and climbing stairs. R elieving Factors Rest T reatment None Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Metoprolol 100mg PO daily 1 year High blood presure Atorvastatin 20mg PO bedtime 1 year High cholesterol Tylenol 650mg PO Q 8 hours PRN Headaches Fish oil 1200mg 1 tab PO daily 1 year supplements Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Patient is hypertensive and high cholesterol. No surgery, reports immunization is up to date. S: Subjective Information the patient or patient representative told you
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Patient is married, lives with his wife and 2 children.He is a civil engineer and enjoys riding his bike a lot but has not done so in 2 years since it got stolen. Denies illcit drug use or tobacco.Social drinker,drinks 2 to 3 bottles on the weekends. Uses his seatbelt while driving and has working smoke detectors at home. Denies routine exercise. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
You've reached the end of your free preview.
Want to read all 10 pages?
- Fall '15
- stable angina