SOAP Note week 1.doc{GRADEDA+}
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SOAP Note Name (Initials): W.K. Date: 11/2/2018 Time: 0930 Age: 18 Sex: M SUBJECTIVE Data Chief Complaint (CC): Reason given by the patient for seeking medical care “in quotes” “I have bee ... n having clear discharge for the last week. It burns when I pee and sometimes even when I’m not.” History of Present Illness (HPI): Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Include the 7 attributes of the symptoms: Location, quality, quantity/severity, timing, remitting/exacerbating, factors, associated manifestations. Patient’s symptoms began about a week ago. Clear discharge out of urethral meatus and burning when urinating. Patient also states it burns sometimes even when he isn’t urinating. More of a burning sensation rather than pain. Patient had unprotected sex about three weeks ago. Medications: (Name of the medication, route, dosage, and reason for med) Medication Intolerances: None Past Medical History (PMH) Allergies (Drugs, Food, and Environmental): NKDA Tobacco, alcohol, or illicit drug use in the past: Tobacco and alcohol Chronic Illnesses/Major traumas: Appendicitis [Show More]
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