NR509_SOAP week2.docx - SOAP Note Template S Subjective Information the patient or patient representative told you Initials TJ Height 170cm Weight 90kg

NR509_SOAP week2.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 170cm 90kg 140/ 81 89 20 98.5F 97 RA Medication: PCN Food: Denies Environment: Cats, Dust History of Present Illness (HPI) Chief Complaint (CC) “increased breathing problems and, inhaler is not working anymore” 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 L ocation lungs D uration Exacerbations last several minutes, exacerbated breathing every 4 hours original episode C haracteristics Wheezeing, chest tightness, denies chest pain A ggravating Factors Worse at night, aggravated by movement, worse when lying flat on back. R elieving Factors Sitting up right and limited exercise T reatment Albuterol inhaler, 2-3 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 Tylenol 1000mg At bednight unknown Headache at bedtime Albuterol 90mcg Every four hours For 12 years Wheezing Advil 600mg Three times a day unknown Menstrual cramps 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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Patient has a history of diabetes type 2 and asthma with a hospitalization for asthma exacerbation when she was 16 years old. She denies needed to be intubated. She states she has had the tetanus booster a few years ago. She denies any surgical history, the flu vaccine, and HPV vaccine. She has had chicken pox when she was a child and has received the polio and measles vaccine as a child. Denies COPD and eymphysema. 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. Patient is in school for her bachelors degree for accounting. She also works at Mid American copy and ship as a supervisor. Patient denies using tobacco/nicotine/vaping products. She drinks alcohol 1-2 times a week. She denies ilicit drug use, but admits to using marijuana in the past. The last time she smoked was when she was 21 years old. Her father passed away in a car accident one year ago and her mother is still alive. Reports
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