SOAP Note week 4.doc{latest 2021and 2021 knowledge {gradedA+}
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SOAP Note Name (Initials): T.P Date: 11/27/2018 Time: 1400 Age: 25 Sex: F SUBJECTIVE Data Chief Complaint (CC): Reason given by the patient for seeking medical care “in quotes” “I am here ... today because my blood pressure has been reading high. I also have a headache.” History of Present Illness (HPI): Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Include the 7 attributes of the symptoms: Location, quality, quantity/sverity, timing, remitting/exacerbating, factors, associated manifestations. Began about 1 week ago. Nothing serious but I have had a headache off and on for about a week. When I checked my blood pressure last, it was 155/90 .” Medications: (Name of the medication, route, dosage, and reason for med ) Orthotricycline PO for birth control da Lexapro 20mg Daily PO for depression Medication Intolerances: N/A Past Medical History (PMH) Allergies (Drugs, Food, and Environmental): N/A Tobacco, alcohol, or illicit drug use in the past: Drinks a few mixed drinks socially with friends. Denies smoking or substance abuse. https://www.coursehero.com/file/36389490/SOAP-Note-week-4doc/ This study resource was shared via Course [Show More]
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