NR 509 Abdominal Pain SOAP NOTE.docx

Document Content and Description Below

NR 509Abdominal Pain SOAP Note .docx SOAP Note Template Initials: E.P. Age: 78 Gender: F Height Weight BP HR RR Temp SPO2 Pain Allergies 157.48 (5’2”) 54 kg (120 lbs) 110/ 70 92 16 37... .0 C 99% 6/10 Medication: Latex (Rxn - itchy skin rash) Food: NKA Environment: NKA History of Present Illness (HPI) Chief Complaint (CC) “Belly pain” 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 She is unsure what caused it, but she started having a difficult time going to the bathroom Location Whole belly but mostly the lower part Duration Consistent for the past 5 days. Pain worse 2-3 days ago Characteristics Dull and crampy Aggravating Factors Movement and eating Relieving Factors Rest Treatment Rest 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 Accupril 10 mg Daily 24 years Hypertension 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. Crohn's disease, Bowel obstruction, Human abdomen [Show More]

Last updated: 1 year ago

Preview 1 out of 12 pages