NR 509 SOAP Note Template Tina Jones week 3. Already Graded A+
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Course
NR 509
Institution
NR 509
SOAP Note Template
Initials: tj Age: 28 Gender: female
Height Weight BP HR RR Temp SPO2 Pain
Rating
Allergies (and reaction)
170 88 Click
or
tap
here
to
ente
r
text.
Clic
k or
tap
here
to
ente
r
text.
Clic
k or
tap
her
e to
...
soap note template initials tj age 28 gender female height weight bp hr rr temp spo2 pain rating allergies and reaction 170 88 click or tap here to ente r text clic k or tap here
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NR 509 SOAP Note Template Tina Jones week 3. Already Graded A+
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: tj Age: 28 Gender: female
Height Weight BP HR RR Temp SPO2 Pain Allergies (and reaction)
Rating
170 88 Click Clic Clic Click Click or Medication: penicillin-hives
or k or k or or tap tap here Food: none
tap tap tap here to to enter Environment: : Cat dander- sneezes, asthma flare-up, pruritus
here here her enter text.
to to e to text.
ente ente ent
r r er
text. text. text.
History of Present Illness (HPI)
Chief Complaint (CC) Patient present to the clinic after having a “fender bender” approx 1 week ago, CC is a BRIEF statement identifying
now the patient is having headaches and neck pain. why the patient is here - in the
Onset 5 days patient’s own words - for instance
Location Pain is located at the crown and back of head and c/o neck pain "headache", NOT "bad headache for 3
days”. Sometimes a patient has more
Duration daily
than one complaint. For example: If
Characteristics Dull, increased with movement the patient presents with cough and
sore throat, identify which is the CC
Aggravating Factors Non- radiating, dull and associated with neck pain and which may be an associated
Relieving Factors Movement of head symptom
Treatment Tylenol for headache
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Proventil 90 mcg, inhaler As needed 30 Asthma exacerbation- Rescue inhaler
for asthma exacerbation
Flovent Patient unaware of daily 30 Asthma management
exact dosage
Tylenol 650mg as needed by As needed 30 For headaches
, mouth
Advil 600 mg as needed by As needed 30 For menstrual cramps
mouth
Metformin 500 mg twice a day Twice a day 30 Patient states she does not take this
by mouth any more
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.
Should include: the accident MVA, should pertain to the Chief complaint, 15mile accident in parking lot, wearing seat belt, rear end fender bender.
Was not drinking alcohol.
Asthma dx age 2.5 yrs old
Diabetes dx at 24yrs old,
Denies surgical history
Past Medical History: DM type 2; Asthma: diagnosed at age 2.5years, HTN
Vaccinations: Reports being up to date with Pneumonia vaccine: 1 year ago; Tetanus Vaccine: 1 year ago. No current with Flu vaccine. Reports that
all childhood vaccines were received.
Past surgical history: None
Past hospital admissions: 3mo since last physical and checkup.; apx. 5 hospital admissions for asthma exacerbations; Last admission related to
asthma was when patient was 16.
Reports all Immunization are up to date
Last Flu vaccine: 5 or 6 years ago per patient, declines at this time
Last Tetanus booster: 1 year ago Meningitis Vaccine at 19yrs old.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Marital Status: Single.
Current birth control methods: Abstinence; History of PO birth control (Last used 2 years ago)
Occupation: Works as a supervisor at Mid-American copy
Education: attending college to obtain a bachelor’s degree in accounting.
Living arrangements: Lives with mother and sister
father deceased from car accident.
Hobbies: Enjoys reading watching tv series and documentaries
Brother lives with fiancée.
Religion: Active in local church.
Substance use: Denies tobacco use and current recreational drug use. Reports cannabis use 3 years ago.
Drinks alcohol (approx twice a month) socially with friends. Last alcoholic beverage, 3 weeks ago.
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