*NURSING > Summary > NR 509 SOAP Note Week 3 (All)

NR 509 SOAP Note Week 3

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RR Temp SPO2 Pain Rating Allergies (and reaction) 170 cm 88 kg 139/ 87 82 16 98.9 99% Medication: Penicillin (Rash/Hives) Food: Denies Environment: Cats (sneezing, eyes itch, runny nose, asth... ma exasperation) History of Present Illness (HPI) Chief Complaint (CC) “After a fender bender 1 week ago I have had headaches and a sore neck.” 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 2 days after car accident Location Head and neck Duration Every day for 5 days Characteristics Dull ache like a crown around the front and back of head Aggravating Factors Movement Relieving Factors Tylenol, rest, and decreased movement Treatment Tylenol, rest, and decreased movement 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 Tylenol 325 mg x2 Every 4-6 hours As needed Headache and neck pain Proventil 90 mcg 2 inhalations As needed Asthma exasperation Ibuprofen 200 mg x3 Every 6-8 hours As needed Menstrual cramps Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, S: Subjective [Show More]

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