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NR 509 SOAP Note WEEK 5, S: Subjective NR 509 Advanced physical assessment
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NR 509 SOAP Note WEEK 5, S: Subjective NR 509 Advanced physical assessment
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SOAP NOTES TEMPLATENR 509 SOAP Note WEEK 5
S: Subjective
NR 509 Advanced physical assessment
, SOAP NOTES TEMPLATE
S: Subjective
Information the patient or patient representative told you.
Initials: EP
Age: 78
Gender: Female
Height: 5’2”
Weight: 120 lbs
BP: 110/70
HR:92
Temp: 37.0 C
SPO2: 99
RR: 16
Pain (1-10): 6
Allergies:
Medication: NKDA
Food: none
Environment: Latex—“itchy rash”
History of Present Illness (HPI)
Chief Complaint (CC): “pain in my belly” and difficulty going to the bathroom
Onset: Constipation 5 days ago with the exception of an episode of was watery diarrhea 3 days ago
Location: “low in abdomen”
Duration: constant x 5 days
Characteristics: dull “crampy” feeling
Aggravating Factors: eating causes bloating and increased pain, physical activity
Relieving Factors: resting helps a little
Treatment: sips of warm water which did not work
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