NR509_SOAP_Note_week3_Yoan.docx - S Subjective Information the patient or patient representative told you SOAP Note Template Initials TJ Age 28 years

NR509_SOAP_Note_week3_Yoan.docx - S Subjective Information...

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SOAP Note TemplateInitials: TJAge: 28 years oldGender: FemaleHeightWeightBPHRRRTempSPO2PainAllergies 170cm88 kg139/87821698.999%3/10Medication: Penicillin (causes rash and hives)Food:NoneEnvironment: Cats, dust (cause asthma exacerbation)History of Present Illness (HPI)Chief Complaint (CC)Headaches with neck pain CC is a BRIEF statement identifying why the patient is here - in the patient’sown words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the pa-tient presents with cough and sore throat, identify which is the CC and which may be an associated symptomOnset1 week ago after car accident, symptoms because 2 days after accident.LocationHeadache at the crown and back of the headDurationLasts 1-2 hours dailyCharacteristicsDull pain while experiencing headacheAggravating FactorsPain when moving her neckRelieving FactorsRest and Tylenol as neededTreatment(PRN) As needed two regular strength TylenolCurrent Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Medication (Rx, OTC, or Homeopathic)DosageFrequencyLength of TimeUsedReason for UseProventil Inhaler 90 mcg2 puffs as neededEvery 4 hours asWheezingS:SubjectiveInformation the patient or patient representative told you
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neededShortness of breathTylenol650 mg (states she takes two tablets)Once a dayThe past few daysHeadachesAdvil200 mg TID PRNFirst couple of days of men-strual cycleCrampingFlovent inhalerClick or tap here to en-ter text.Click or tap here to enter text.Click or tap here to enter text.AsthmaClick or tap here to enter text.Click or tap here to en-ter 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, hospi-talizations, and surgeries. Depending on the CC, more info may be needed.Tina was diagnosed with Diabetes Mellitus type 2 at the age of 24 years old. She is non-compliant with taking her metformin, as well as checking blood sugar on a regular basis. Diagnosed with asthma at the age of 2 and a half. Has been taking her inhaler as needed for asthma exacerbation; currently it is not being as effec-tive as it was. Is now on Flovent which has been providing relief for maintenance. Suffers from heavy periods that include cramping as well as tenderness. Tina has irregular periods which last between 9-10 days.Immunizations are current, has received vaccinations for childhood.Flu shot received last 5 to 6 years ago.Last tetanus shot was about two years ago.Last pap smear was done about 4 years ago, and was normal. Tina has Polycystic ovarian syndrome.
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