Brown_ Susan_NR509_Week 2_SOAP_Note.docx - SOAP Note Template S Subjective Information the patient or patient representative told you Initials TJ Height

Brown_ Susan_NR509_Week 2_SOAP_Note.docx - SOAP Note...

This preview shows page 1 - 3 out of 8 pages.

SOAP Note Template Initials : TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 89kg 140/ 81 89 20 98.5 97% Medication: Penicilllin- rash/hives; as a child Food: NKFA Environment: Cats and dust- itchy watery eyes,runny nose, exacerbates asthma History of Present Illness (HPI) Chief Complaint (CC) “Breathing problems” 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 Diagnosed with asthma at age 2 and ½ years; exacerbation two days ago L ocation Chest and lungs D uration Two days ago. Episodes occurring approximately every 4 hours or “5 times a day” C haracteristics SOB not well relieved by inhaler, DOE, wheezing, difficulty breathing while lying flat, dry cough, waking at night due to SOB A ggravating Factors Expsosure to cats and dust. Bursts of physical exertion “run up stairs to class.” “Past couple of days, though it doesn’t seem like anything in particular is causing it.” R elieving Factors Pronventil inaler. “Once I use my inhaler it only takes a minute or two for my breathing to go back to normal…that’s not what’s been happening recently , though.” T reatment Proventil inhaler 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 Proventil 90mcg 2 inhalations Every 4 hours prn 25.5 years Asthma: wheezing, SOB Tylenol 500mg 2 tablets po Every 6 hours prn PRN Headache Advil 200mg 3 tablets po Every 4 – 6 hours prn PRN Menstrual cramps 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. 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. S: Subjective Information the patient or patient representative told you
Image of page 1
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. Asthma: Diagnosed with asthma at age 2 and ½ years Diabetes: Diagnosed at 24 years of age. Has not taken medication for diabetes for 3 years. Manages diabetes by avoiding sugar and trying to stay active. Does not self monitor blood glucose. Hospitalizations: Patient estimates being hospitalized 5 times for asthma as a child. Last hospitalization age 16 years. Denies previous intubation for asthma.
Image of page 2
Image of page 3

You've reached the end of your free preview.

Want to read all 8 pages?

  • Fall '15

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes