NR 509Abdominal Pain SOAP Note .docx
SOAP Note Template
Initials: E.P. Age: 78 Gender: F
Height Weight BP HR RR Temp SPO2 Pain Allergies
157.48
(5’2”)
54 kg
(120
lbs)
110/
70
92 16 37.0 C 99% 6/10 Medication
...
NR 509Abdominal Pain SOAP Note .docx
SOAP Note Template
Initials: E.P. Age: 78 Gender: F
Height Weight BP HR RR Temp SPO2 Pain Allergies
157.48
(5’2”)
54 kg
(120
lbs)
110/
70
92 16 37.0 C 99% 6/10 Medication: Latex (Rxn - itchy skin rash)
Food: NKA
Environment: NKA
History of Present Illness (HPI)
Chief Complaint (CC) “Belly 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 3
days”. Sometimes a patient has more
than one complaint. For example: If
the patient presents with cough and
sore throat, identify which is the CC
and which may be an associated
symptom
Onset She is unsure what caused it, but she started having a difficult time going to the
bathroom
Location Whole belly but mostly the lower part
Duration Consistent for the past 5 days. Pain worse 2-3 days ago
Characteristics Dull and crampy
Aggravating Factors Movement and eating
Relieving Factors Rest
Treatment Rest
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic)
Dosage Frequency Length of Time
Used Reason for Use
Accupril 10 mg Daily 24 years Hypertension
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Crohn's disease,
Bowel obstruction,
Human abdomen
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