NR509 Week 5 Soap Note.docx
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NR509 Week 5 Soap Note.docx 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 [Show More]
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