*NURSING > CASE STUDY > NR509 Week 1 SOAP Note (All)
SOAP NOTES TEMPLATE S: Subjective Information the patient or patient representative told you. Initials: JT Age: 28 years Gender: Female Height: 170cm Weight: 90kg BP: 142/82 HR: 86 T ... emp: 101.1 SPO2: 99% Pain (1-10): 7 Allergies Medication: Penicillin Food: No known allergy Environment: Cats History of Present Illness (HPI) 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 Chief Complaint (CC): Acute pain of right foot Onset: 7 days prior to exam Location: Right foot, plantar aspect Duration: 1 week Characteristics: Throbbing, stabbing Aggravating Factors: Bearing weight, ambulation Relieving Factors: Rest, elevation, pain medication Treatment: Tramadol [Show More]
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