Nr509 week 4 soap note - Study guides, Class notes & Summaries

Tina Jones Week 1 NR509 SOAP NOTES TEMPLATE Tina Jones Week 1 NR509 SOAP NOTES TEMPLATE S: Subjective Information the patient or patient representative told you. Initials: T.J Age: 28 Gender: Female Height: 170cm Weight: 90kg BP: 142/82 HR: 86 Temp: 101.1 SPO2: 99% Pain (1-10): 7/10 Allergies Medication Penicillin = Rash/Hives Food No Known Allergies Environment Cat Dander & Dust = Sneezing, Itchy eyes, Wheezing History of Pre...

NR509 Week 4 SOAP Note Template

Exam (elaborations) NR 509 WEEK 4 SOAP NOTE (NR509) SOAP Note Template Initials: BF Age: 58 Gender: Male Height Weight BP HR RR Temp SPO2 Pain Allergies 5’ 11 197lbs 146/ 90 104 19 36.7C 98% Medication: Codeine : reports causes nausea and vomiting Food: none Environment: none History of Present Illness (HPI) Chief Complaint (CC) Chest 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...

S: Subjective – Information the patient or patient representative told you O: Objective – Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. A: Assessment – Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagno...

NR509 Week 2 SOAP Note – Chamberlain College of Nursing S: Subjective Information the patient or patient representative told you. Initials: JT Age: 28 years Gender: Female Height: 170cm Weight: 89kg BP: 140/81 HR: 89 Temp: 98.5 SPO2: 97% Pain (1-10): 0 Allergies Medication: Penicillin Food: No known allergy Environment: Cats History of Present Illness (HPI) CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instanc...

Exam (elaborations) NR511 WEEK 1-3 LECTURES Primary care is different than tertiary care. The types of problems that are solved in primary care are different than those seen in acute- or critical-care settings, which you may be used to as a bedside nurse. Upper respiratory infections, abdominal complaints, skin rashes, and vague somatic complaints are problems that are not often encountered in the hospital setting. Even chronic conditions present differently in primary care. HTN, CHF, ...

NR 509 WEEK 4 SOAP NOTE