NR 509 summary Comprehensive Health History SOAP Note

SOAP Note Template Initials: T. J. Age: 28 Gender: F Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 90 kg 142/ 82 86 19 101.1 F 99% Medication: Penicillin Food: NKA Environment: NKA History of Presen ...

SOAP Note Template Initials: T. J. Age: 28 Gender: F Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 90 kg 142/ 82 86 19 101.1 F 99% Medication: Penicillin Food: NKA Environment: NKA History of Present Illness (HPI) Chief Complaint (CC) “Painful foot wound” 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 Pt tripped and scraped right foot on the edge of the step Location Sole of right foot Duration Few days Characteristics Red, swollen, white/off-white pus Aggravating Factors Putting weight on foot Relieving Factors Medication Treatment Tramadol 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 Tramadol 50 mg 100 mg TID 2 days Pain Proventil inhaler 90 mcg/spray 2-3 times a week Click or tap here to enter text. Asthma Tylenol 500 mg Once a week Click or tap here to enter text. Headache Advil 200 mg 600 mg Click or tap here to enter text. 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. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.