NR509_SOAP_Note_JRodriguez-WEEK3.docx - SOAP Note Template S Subjective Information the patient or patient representative told you Initials T.J Height

NR509_SOAP_Note_JRodriguez-WEEK3.docx - SOAP Note Template...

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SOAP Note Template Initials : T.J Age: 28 years old Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88 kg 139/ 87 82 16 98.9 99% Medication: Penicillin (Causes her rash and hives) Food: N/A Environment: Cats and dust (Causes her asthma exacerbations History of Present Illness (HPI) Chief Complaint (CC) Headaches and her neck hurts 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 Since the car accident (Couples days) then symptoms began 2 days after that. L ocation Is at the crown of the head and the back of her head D uration It is everyday and it last 2 to 3 hours C haracteristics Pain is a dull ache A ggravating Factors When moving the neck R elieving Factors Tylenol and rest T reatment Two regular strength Tylenol. 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 Inhaler 90mcg 2 pufss as needed Every 4 hours as needed Shortness of Breath and wheezing Tylenol 650 mg (2 tabs) Once a day For the last past days Headaches Flovent Click or tap here to enter text. Click or tap here to enter text. Asthma 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. 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. S: Subjective Information the patient or patient representative told you
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Tina was diagnose with Asthma at 2.5 years old, uses the proventil inhaler for exacerbations and Flovent for maintanance. Diabetes was diagnose at the age of 24 years old, she is non compliant with taking metformin as well as doing her accuchecks, no diabetic diet follow. Tina has Polyscystic ovarian syndrome, she reports heavy flow periods with cramping, periods are irregular and last 9 to 10 days. Last pap smear was around 5 years ago. Vaccinations: her child vaccinations were received and her last tetanus vaccine about two years ago. She haven’t seen the ophtamologist. Last time was when she was a girl. As well for the dentist, she saw one as a child the last time.
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  • Fall '15
  • Headaches, Tina, Medical diagnosis, Headache

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