_TJ_SOAP_Wk2.docx - SOAP Note Template S Subjective Information the patient or patient representative told you Initials T.J Height 170 cm Weight 89 kg

_TJ_SOAP_Wk2.docx - SOAP Note Template S Subjective...

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SOAP Note Template Initials : T.J. Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 89 kg 140/ 81 89 20 98.5 97% Medication: Penicillin- hives (during childhood) Food: NKA Environment: Dust: sneezing, itchy eyes, wheezing Cats:sneezing, itching eyes, wheezing; Exercise: wheezing History of Present Illness (HPI) Chief Complaint (CC) 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 X 2 days L ocation Generalized chest D uration X 2 days intermittently C haracteristics Chest tightness A ggravating Factors Position, exertion, Cats R elieving Factors Proventil Inhaler, temporary T reatment Proventil inhaler; 3 puffs q4h 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 (Albuterol) MDI 90 mcg PRN for asthma As Needed Wheezing, SOB 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. 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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Type 2 DM (Diagnosed at age 24) Asthma (Diagnosed at age 2.5) Influenza Vaccination: Unknown Tetanus Vaccination: Unknown 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. Current student: Majoring in Accounting Supervisor – Mid-American Copy & Ship Denies current sexual activity. Sexual activity began at age 18. Denies Hx of STI Lives with supportive mother and sister. Hobbies: Attending church and spending time with family and friends. Smoking: Denies; Illicit drugs: Hx of marijuana use; Last time: at age 20/21 yo; Alcohol: Unknown Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
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