NR 509 SOAP Note Template-2022-Chamberlain
Document Content and Description Below
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 headach... e 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 While doing strenuous acitivties, earlier this month. Location Middle of chest. Does not radiate. Duration 3 episodes for the past month. Each episode lasts for a couple of minutes. Characteristics Chest tightness in the middle of chest without radiation. Aggravating Factors Yard work and climbing stairs at work. Relieving Factors Taking a break or sat down to rest. Treatment Reports no treatment uses 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 Atorvastatin (Lipitor) PO 10mg Daily at HS One year High Cholesterol Metoprolol (Lopressor) PO 100mg Daily One year High blood pressure CONTINUED........ [Show More]
Last updated: 2 years ago
Preview 1 out of 10 pages
Buy this document to get the full access instantly
Instant Download Access after purchase
Buy NowInstant download
We Accept:
Reviews( 0 )
$12.00
Can't find what you want? Try our AI powered Search
Document information
Connected school, study & course
About the document
Uploaded On
May 24, 2022
Number of pages
10
Written in
Additional information
This document has been written for:
Uploaded
May 24, 2022
Downloads
0
Views
106
