NR509 Soap Note_Week1_TinaJones.docx - SOAP Note Week 1 NR...

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SOAP Note Week 1: NR 509Initials: T.J.Age: 28Gender: FemaleHeightWeightBPHRRRTempSPO2Pain RatingAllergies (and reaction)170 cm90 kg142/828619101.199%Medication: Penicillin allergy causes rash and hivesFood: NoneEnvironment: Cats allergy trigger her asthma and causes wheezing, sneezing, and itchingHistory of Present Illness (HPI)Chief Complaint (CC)Right Foot PainCC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3days”. 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 symptomOnset1 week agoLocationPlantar surface of right footDurationInitial injury a week ago with worsening pain over the last 2 daysCharacteristicsThrobbing and sharp pain when standingAggravating FactorsWeight-bearingRelieving FactorsPain medications and restTreatmentCleanses wound with hydrogen peroxide, applies Neosporin, and changes dressing twice dailyCurrent Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Medication (Rx, OTC, or Homeopathic)DosageFrequencyLength of TimeUsedReason for UseProventil Albuterol Inhaler90mcg/spray MDI; 2-3 puffsEvery 4 hours as needed for shortness of breathe, wheezingSince childhoodAsthmaAdvil (Ibuprofen)200mg tabletsEvery 8 hours as needed for dysmenorrheaUnknownDysmenorrheaTylenol325mg tabletsEvery 4-6 hours as neededfor headacheUnknownHeadacheTramadol50 mg tablets2 pills every 8 hours as needed for pain2 day; Last dosewas this Pain Relief for Right FootS:SubjectiveInformation the patient or patient representative told you
morningNeosporin1 applicationTwice daily1 weekWound InfectionPast 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.Ms. Jones is active in church and with family. She enjoys bible study and volunteering at her local church. Patient reports being “up to date on shots’, reports receiving all necessary childhood immunizations, has not received annual flu vaccine and was given last tetanus vaccination was in the past year. Patient was diagnosed with Type 2 diabetes at the age of 24. Patient was diagnosed with Asthma at 2.5 years old, last hospitalizationwas at the age of 16 due to an Asthma attack, estimates 5 total hospitalizations for asthma as a child and teen. Reports irregular and heavy periods, menstruating every 6 weeks to 2 months, and periods can last up to 9 days.Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinentdata. Include health promotion such as use seat belts all the time or working smoke detectors in the house.

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