RKent SOAP Note Corneal Abrasion.docx - S.O.A.P Note u2013...

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S.O.A.P. Note – Ryan Kent – Assignment 2.1 – NURS 621 CASE ID# ____________________________ S ubjective O bjective A ssessment (diagnosis [primary and differential diagnosis]) P lan (treatment, education, and follow up plan) Chief mplaint What brought you here today…(eg. headache) “My right eye that has been irritated for one day. I’ve got eye redness and constant tearing. I wear contacts and felt like I got something in it yesterday during yard work.” History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset One day ago. Right eye. Constant. Constant redness and tearing. “Feels like I’ve got something in it.” Yardwork. N/a. N/a. Mild-Moderate Pt has been active over the last day and denies fever, weakness, night sweats, and change in weight, lyphadenopathy and fatigue. Location Duration Character Aggravating/associated factors Relieving factors Temporal factors – other things going on Severity Past Medical History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications No history of any past illness, injuries, surgery, hospitalization or psychiatric illness Family History Include Parents, siblings; grandparents if applicable/known, cause of death, Both parents are hypertensive. Maternal grandfather is deceased from MI in 2006. Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known Lives with both parents but the mother is mostly away from home and only available over the weekends. Most of the time is spent with the grandmother

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