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NR509 week 1 SOAP Note exam questions
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NR509 week 1 SOAP Note exam questions NR509 week 1 SOAP Note exam questions NR509 week 1 SOAP Note exam questions
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1SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: TJ Age: 28 Gender: Female
Heigh Weigh BP HR RR Temp SPO2 Pain Allergi
t t es
170c 90kg 142/ 86 19 101.1 99% Medication: Penicillin (hives, rash)
m
82 F Food: none
Environment: Cats (asthma flare up, sneezing, itchy
eyes)
History of Present Illness (HPI)
Chief Complaint Infected right foot wound CC is a BRIEF statement
(CC)
identifying why the patient
Onset 1week ago
is here - in the patient’s own
Location Right foot on the bottom words - for instance
Duration 1 week and few days "headache", NOT "bad
Characteristics Swollen near the scrape, open, red, and painful but worse headache for 3 days”.
when walking on it. Sometimes a patient has
Aggravating Walking. movement more than one complaint.
Factors
For example: If the patient
Relieving Factors Resting and pain medications
presents with cough and
Treatment Tramadol 50mg PO sore throat, identify which
is the CC and which may be
an associated symptom
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or
,homeopathic products. 2
Medication Length of
Dosag Frequency Time Reason for Use
(Rx, OTC, or e Used
Homeopathic)
Ibuprofen 200mg Q 6 hrs PRN PRN PRN for menstrual pain.
Proventil 90mcg 2 puffs TID PRN PRN since PRN asthma symptoms.
childhood
Tramadol 50mg PRN every 8 hrs PRN PRN for wound pain in right
foot.
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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.
, 3
Asthma, Diabetes, no hx of surgeries, last hospital admission as a child for asthma exacerbation.
Immunization status up to date. Last Tetanus :
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.
Manager for , Student to study accounting, close with mother and sister (living together), Brother lives
elsewhere, father deceased from car accident. Denies tobacco use. Alcohol use socially with friends ( rum
and diet coke). Drives and uses seatbelt, working smoke detector in house.
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition,
contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included.
Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Mother- high cholesterol and hypertension
Father (deceased at 58 car accident)- T2DM, high cholesterol
and hypertension. Brother 25 y.o.- Obesity
Sister 14 y.o -Asthma
maternal grandma- HTN and high
cholesterol maternal grandpa-
HTN and high cholesterol.
paternal grandma-HTN and high
cholesterol
paternal grandpa- (deceased) colon cancer, HTN, diabetes.
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis
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