NR 509 Week 5 SOAP note
SOAP Note Template Initials: E.P. Age: 78 Gender: female Height Weight BP HR RR Temp SPO2 Pain Allergies 157 cm 54kg 110/ 70 92 16 37.0 99% Medication: NKDA Food: None Environment: Latex History of Present Illness (HPI) Chief Complaint (CC) “I have some pain in my belly and difficulty going to the bathroom.” 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 Onset 5 days ago, with pain increasing the last 2-3 days Location Lower left quadrant of abdomen Duration Constant Characteristics Began as “general discomfort” and “Dull crampy feeling” Aggravating Factors Moving and eating Relieving Factors Rest, sitting still, small sips of water Treatment Small sips of water, thus far no medical treatment or medications 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 Accupril 10mg 0800 Daily 24 years HTN Chamomile tea One cup HS Every 2-3 days 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.
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