Running Head: MEDICAL DOCUMENTATION 1 SOAP & Narrative Note Assignment Julianne Williams Stockton University
MEDICAL DOCUMENTATION 2 PART I – SOAP Note Patient Name: MS Date Examined: 11/1/2019 Caregiver Name: Julianne Williams ______________________________________________________________________________ SUBJECTIVE: A twenty-three year old Hispanic female, with no previous history of health complications reported intense pain, nausea, and vomiting at work. She reported experiencing a high fever, severe H/A , muscle aches, and fatigue as well. The employer believed this to be pregnancy symptoms or from exhaustion. Due to her symptoms, she was sent home but they still persisted throughout the day and into the night. The following day, the patient was driven to an out-patient facility by her husband. OBJECTIVE: Upon arrival, patient appeared to have puffy, red eyes. Patient was groaning while moving. Patient appeared to have rashes and swollen glands too. VS: BP - 107/72 mm Hg, Pulse - 95 beats per minute, T – 103.2° F, Breathing – 32 breaths per minute.
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