NR509- week 3 SOAP_Note final.docx - SOAP Note Template S Subjective Information the patient or patient representative told you Initials TJ Height 170cm

NR509- week 3 SOAP_Note final.docx - SOAP Note Template S...

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SOAP Note Template Initials : TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88kg 139/ 87 82 16 98.9F 99% Medication: Penicillin (rash/ hives) Food: none Environment: Cats, dust (asthma flares up, itchy, watery eyes, sneezing) History of Present Illness (HPI) Chief Complaint (CC) Headache 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 5 days ago L ocation Pain is located at the crown and back of head. D uration Intermittent- daily-lasts for 1-2hrs per episode. C haracteristics Dull headache, non- radiating, associated with neck pain A ggravating Factors Movement of head R elieving Factors Tylenol- improved pain to 3/10 ,rest T reatment No other treatment 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 2 puffs PRN for asthma PRN Rescue inhaler for asthma exacerbation Flovent Patient unaware of exact dosage BID Daily Mainenence for Asthma Tylenol 2- regular strength tabs Once a day Once a day for 5 days For headache Advil 200mg PRN PRN For menstrual cramps N/A 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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Should include: the accident MVA, should pertain to the Chief complaint, 15mile accident in parking lot, wearing seat belt, rear end fender bender. Was not drinking alcohol. (Asthma dx age 2.5 yrs old, Diabetes dx at 24yrs old, Denies surgical history, last hospital admission at 16 yrs old for asthma exacerbation. Reports all Immunization are current at this visit, Last Flu vaccine: 5 or 6 years ago per patient, declines at this time Last Tetanus booster: two years ago Reports Meningitis Vaccine at 19yrs old. 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. Supervisor at Mid-American Copy & Ship, Bachelor’s accounting student, Hobbies:Reading, watchingTV, hanging with friends and going to church. Close with mother and sister (living together), Brother lives with fiancee, father deceased from car accident. Denies tobacco use. Alcohol use socially with friends ( rum and diet coke drink of choice). Drives and always uses a seatbelt, working smoke detector in house.
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