Chamberlain College of Nursing - NR 509soap. week 3
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SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88kg 139/8 7 82 16 98.9 99% 3/10 Medication: Penicillin Food: None Environment:cats,... dust History of Present Illness (HPI) Chief Complaint (CC) “Well I got into a fender bender a week ago and I’ve been getting these headaches ever since and my neck is sore too” 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 5 days ago two days after s/p motor vehicle accident Location Crown of head and posterior head, posterior neck [Show More]
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