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

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
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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

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.