NURS 612 Assignment 3.3 EENT documentation.docx - S.O.A.P...

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S.O.A.P. Note Template CASE ID# ______EENT Video_____ S ubjective O bjective A ssessment (diagnosis [primary and differential diagnosis]) P lan (treatment, education, and follow up plan) Chief mplaint What brought you here today…(eg. headache) “I think I have a sinus infection”. History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Caucasian female presents today with complaints of pressure and congestion in sinuses for 2 weeks. Patient complains of foul smell and taste, headaches, fatigue, cough at night, bilateral ear pain, with a sore throat in the morning and at night. Patient has tried OTC Sudafed and OTC Tylenol with minimal relief. Patient denies fever, chills, or sweats. Cough is worse when laying down/flat. The pain is described as “terrible”, and as “pressure” or “congestion”. Patient stated, “feels like nasal polyps might be back, but I don’t know”. Location Duration Character Aggravating/associated factors Relieving factors Temporal factors – other things going on Severity Past Medical History Adult Illnesses,

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