SOAP_Note.docx - SOAP Note Template S Subjective Information the patient or patient representative told you Initials TJ Height 170 cm Weight 89 kg Age

SOAP_Note.docx - SOAP Note Template S Subjective...

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SOAP Note Template Initials : TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 89 kg 140/ 81 89 20 98.5 F 97% Medication: Penicillin – hives in childhood Food: None Environment: Cats – sneezing, itchy eyes, wheezing; Dust – sneezing, itchy eyes, wheezing History of Present Illness (HPI) Chief Complaint (CC) Increased Dyspnea and shortness of breath 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 2 days ago L ocation After visiting cousin’s house with cats, triggering cat allergy D uration Consistent over 2 days C haracteristics “not full asthma attack” but worse than usual. Wheezing and chest tightness. Dry cough A ggravating Factors Worse at night and when lying flat on back. Worsened with movement. R elieving Factors Proventil inhaler some relief but not as effective T reatment Proventil inhaler – using every 4 hours and needing more than 2 puffs 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/inhalation 2-3 inhalations daily Click or tap here to enter text. Asthma Advil 200mg tablets 600 mg Three times a day Click or tap here to enter text. Menstrual Cramps Tylenol 500mg tablets 500 mg Once per week Click or tap here to enter text. Headache 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
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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. Health Maintenance: Last eye exam: as a child Last dental exam: several years ago Immunizations: “Up to date on shots”; has not received flu vaccine; last tetanus vaccine within the past year. Major Illnesses: Diabetes – diagnosed with Type 2 at age 24; tries to manage with diet, “stays away from sweets” and drinks diet soda; not currently taking any diabetic medications; previously prescribed metformin – last use was 3 years ago due to “being sick of dealing with it”, dislikes taking a daily pill, and not wanting to check sugar daily.
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