NR509 Week 3 SOAP Note.docx - SOAP NOTES TEMPLATE S Subjective Information the patient or patient representative told you Initials JT Age 28 years

NR509 Week 3 SOAP Note.docx - SOAP NOTES TEMPLATE S...

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SOAP NOTES TEMPLATES: SubjectiveInformation the patient or patient representative told you.Initials: JTAge: 28 yearsGender: FemaleHeight: 170cmWeight: 88kg BMI: 30.5BP: 139/87HR: 82 RR: 16Temp: 98.9SPO2: 99%Pain (1-10): 3/10AllergiesMedication: Penicillin—Rash Food: No known allergyEnvironment: Cats—Asthma exacerbationsHistory of Present Illness (HPI)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 anassociated symptomChief Complaint (CC):Headache and neck stiffnessOnset: Ms. Jones reports experiencing headaches and neck stiffness for approximately 5 days. She reports, 1 week ago, being the restrained, front passenger in her friend’s car when they were rear-ended at low speed.Location:Head and neckDuration:Approximately 5 daysCharacteristics:Dull ache to the crown and back of head. Stiffness of neckAggravating Factors:Physical activityRelieving Factors:TylenolTreatment:NACurrent Medications
SOAP NOTES TEMPLATEMedicationDosageFrequencyLength of TimeUsedReason for UseProventil inhalerAlbuterol 90mcg/sprayPRNLong termAsthmaTylenol500mgPRNUnknownHeadachesAdvil600mgTID PRNUnknownMenstrual crampsPast 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.She has asthma and diabetes type II and exhibits signs and symptoms of peripheral neuropathy to the bilateral soles of the feet. She denies any surgical history and reports that her last hospitalization for asthma when she was in high school. She also reports intermittent headaches and blurry vision whenever she has been studying for long periods oftime. She denies having been to an optometrist since she was a child. She reports being treated by a respiratory specialist until the provider moved away in the past few years. She reports that she is up to date on all childhood immunizations. Until seeking primary care at this clinic 11 months ago, she was non-compliant with all health management regimen for several years.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 allthe time or working smoke detectors in the houseMs. Jones is very active in church and with family, goes out occasionally with friends dancing, and enjoys bible study and volunteering with her church. She previously lived alone but moved back in with her mom and younger sister to help with finances after the death of her father. She is working on her bachelor’s degree in accounting. She does not use tobacco products or illicit drugs but reports that she tried both when younger. Ms. Jones drinks diet coke soda and drinks alcohol socially a couple times per month. She is currently single, not sexually active and not

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