Bundle > NR509 Week 1,2,3,4&5 SOAP Note – Chamberlain College of Nursing

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NR509 Week 1,2,3,4&5 SOAP Note – Chamberlain College of Nursing

SOAP Note Template Initials: T.J. Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 90 kg 142/ 82 86 19 101.1 99% Medication: Penicillin- rash/hives Food: no known ... food allergies Environment: Cat dander- sneezes, pruritus, asthma flare-up History of Present Illness (HPI) Chief Complaint (CC) Infected wound to foot 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 Wound occurred a week go with pain getting worse 2 days ago Location Plantar aspect of right foot Duration 1 week Characteristics Red, swollen, pus, warm to touch Aggravating Factors Walking and weight bearing Relieving Factors Pain medications and resting Treatment Cleans with soap and water twice a day, uses Neosporin twice a day, covers with a bandage 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 Three times a day (TID) 2 days Pain Metformin unknown Twice a day (BID) 3 years ago Diabetes Albuterol Inhaler 90 mcg PRN (2-3 times a week) 3 days ago Asthma Advil 600 mg PRN TID unknown Menstrual Cycle 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. Asthma, Type 2 Diabetic [Show More]

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 *NURSING> SOAP NOTE > NR509 Week 1 SOAP Note – Chamberlain College of Nursing | NR 509 Week 1 SOAP Note – Grade A (All)

NR509 Week 1 SOAP Note – Chamberlain College of Nursing | NR 509 Week 1 SOAP Note – Grade A

SOAP Note Template Initials: T.J. Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 90 kg 142/ 82 86 19 101.1 99% Medication: Penicillin- rash/hives Food: no known...

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SOAP NOTE

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 *NURSING> SOAP NOTE > NR509 Week 2 SOAP Note – Chamberlain College of Nursing | NR 509 Week 2 SOAP Note – Grade A (All)

NR509 Week 2 SOAP Note – Chamberlain College of Nursing | NR 509 Week 2 SOAP Note – Grade A

SOAP NOTES TEMPLATE S: Subjective Information the patient or patient representative told you. Initials: JT Age: 28 years Gender: Female Height: 170cm Weight: 89kg BP: 140/81 HR: 89 T...

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SOAP NOTE

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 *NURSING> SOAP NOTE > NR509 Week 3 SOAP Note {2022} – Chamberlain College of Nursing | NR 509 Week 3 SOAP Note {2022} – Grade A (All)

NR509 Week 3 SOAP Note {2022} – Chamberlain College of Nursing | NR 509 Week 3 SOAP Note {2022} – Grade A

SOAP NOTES TEMPLATE S: Subjective Information the patient or patient representative told you. Initials: JT Age: 28 years Gender: Female Height: 170cm Weight: 88kg BMI: 30.5 BP: 139/87...

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SOAP NOTE

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 *NURSING> SOAP NOTE > NR509 Week_4_SOAP_Note - Chamberlain College of Nursing | NR 509 Week_4_SOAP_Note - CHEST PAIN (All)

NR509 Week_4_SOAP_Note - Chamberlain College of Nursing | NR 509 Week_4_SOAP_Note - CHEST PAIN

SOAP Note Template Initials: BF Age: 58 Gender: Male Height Weight BP HR RR Temp SPO2 Pain Allergies 5’ 11 197lbs 146/ 90 104 19 36.7C 98% Medication: Codeine : reports causes nausea and vomiting...

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SOAP NOTE

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 *NURSING> SOAP NOTE > NR509 Week_5_SOAP_Note - Chamberlain College of Nursing | NR 509 Week_5_SOAP_Note - BELLY PAIN (All)

NR509 Week_5_SOAP_Note - Chamberlain College of Nursing | NR 509 Week_5_SOAP_Note - BELLY PAIN

SOAP Note Template Initials: E.P. Age: 78 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 5’ 2 120lbs 110/ 70 92 16 37.0C 99% Medication: NKDA Food: Denies Environment: Latex (it...

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SOAP NOTE

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 *NURSING> SOAP NOTE > NR509 Week 3 SOAP Note {2022} – Chamberlain College of Nursing | NR 509 Week 3 SOAP Note {2022} – Grade A (All)

NR509 Week 3 SOAP Note {2022} – Chamberlain College of Nursing | NR 509 Week 3 SOAP Note {2022} – Grade A

SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88kg 139/ 87 82 16 98.9F 99% Medication: Penicillin (rash/ hives) Food: none Environ...

By Nutmegs

SOAP NOTE

$12

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