NR509 SOAP Notes for WEEK 1, 2, 3, 4, 5, 6 & 7

S: Subjective Information the patient or patient representative told you. Initials: BF Age: 58 years old Gender: Male Height: 5’11” Weight: 197lbs BP: 146/90 HR: 104 Temp: 19 SPO2: 98% Pain (1-10): 0/10 Allergies Medication: Codeine—Nausea and vomiting Food: No Known Fo...

History of Present Illness (HPI) Chief Complaint (CC) “Breathing problems” 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:...

S: Subjective Information the patient or patient representative told you. Initials: JT Age: 28 years Gender: Female Height: 170cm Weight: 90kg BP: 142/82 HR: 86 Temp: 101.1 SPO2: 99% Pain (1-10): 7 Allergies Medication: Penicillin Food: No known allergy Environment: Cats Hi...

History of Present Illness (HPI) Chief Complaint (CC) “Belly pain” 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...

SOAP NOTES TEMPLATE S: Subjective Information the patient or patient representative told you. Initials: JT Age: 28 years Gender: Female Height: 170cm Weight: 88kg BMI: 30.5 BP: 139/87 HR: 82 RR: 16 Temp: 98.9 SPO2: 99% Pain (1-10): 3/10 Allergies Medication: Penicillin—Rash...

History of Present Illness (HPI) Chief Complaint (CC) c/o cough, runny nose, right ear pain,sore throat 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 on...