NR 509 SOAP Note Template Tina Jones week 3 Latest 2021

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SOAP Note Template Initials: tj Age: 28 Gender: female Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction) 170 88 Click or tap here to ente r text. Clic k or tap here... to ente r text. Clic k or tap her e to ent er text. Click or tap here to enter text. Click or tap here to enter text. Medication: penicillin-hives Food: none Environment: : Cat dander- sneezes, asthma flare-up, pruritus History of Present Illness (HPI) Chief Complaint (CC) Patient present to the clinic after having a “fender bender” approx 1 week ago, now the patient is having headaches and neck 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 5 days Location Pain is located at the crown and back of head and c/o neck pain Duration daily Characteristics Dull, increased with movement Aggravating Factors Non- radiating, dull and associated with neck pain Relieving Factors Movement of head Treatment Tylenol for headache 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 Proventil 90 mcg, inhaler As needed 30 Asthma exacerbation- Rescue inhaler for asthma exacerbation Flovent Patient unaware of exact dosage daily 30 Asthma management Tylenol 650mg as needed by As needed 30 For headaches S: Subjective Information the patient or patient representative told you mouth Advil 600 mg as needed by mouth As needed 30 For menstrual cramps Metformin 500 mg twice a day by mouth Twice a day 30 Patient states she does not take this any more 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. Should include: the accident MVA, should pertain to the Chief complaint, 15mile accident in parking lot, wearing seat belt, rear end fender bender. Was not drinking alcohol. Asthma dx age 2.5 yrs old Diabetes dx at 24yrs old, Denies surgical history Past Medical History: DM type 2; Asthma: diagnosed at age 2.5years, HTN Vaccinations: Reports being up to date with Pneumonia vaccine: 1 year ago; Tetanus Vaccine: 1 year ago. No current with Flu vaccine. Reports that all childhood vaccines were received. Past surgical history: None Past hospital admissions: 3mo since last physical and checkup.; apx. 5 hospital admissions for asthma exacerbations; Last admission related to asthma was when patient was 16. Reports all Immunization are up to date Last Flu vaccine: 5 or 6 years ago per patient, declines at this time Last Tetanus booster: 1 year ago Meningitis Vaccine at 19yrs old. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Marital Status: Single. Current birth control methods: Abstinence; History of PO birth control (Last used 2 years ago) Occupation: Works as a supervisor at Mid-American copy Education: attending college to obtain a bachelor’s degree in accounting. Living arrangements: Lives with mother and sister father deceased from car accident. Hobbies: Enjoys reading watching tv series and documentaries Brother lives with fiancée. Religion: Active in local church. Substance use: Denies tobacco use and current recreational drug use. Reports cannabis use 3 years ago. Drinks alcohol (approx twice a month) socially with friends. Last alcoholic beverage, 3 weeks ago. Denies tobacco use. Drives and always uses a seatbelt, working smoke detector in house. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Father- died from accident. Type 2 diabetes, high cholesterol and blood pressure. Mother-Living, high cholesterol, and blood pressure paternal grandfather- colon cancer, high blood pressure, diabetes, high cholesterol brother's- obesity Mother: Hypertension, High cholesterol Father: (Deceased) at age 58 in mva: HTN, Type II DM, high cholesterol Paternal Grandfather: (Deceased): Colon CA. Type II DM, HTN, high cholesterol Paternal Grandmother: HTN, high cholesterol Maternal Grandmother: HTN, high cholesterol Maternal Grandfather: (Deceased): Cardiovascular Accident. HTN, High cholesterol Sister: Asthma Brother: No health history Maternal grandmother- stroke, high blood pressure and cholesterol. paternal grandfather-passed away paternal grandmother's blood pressure, high cholesterol. sister's-asthma. Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional If patient denies all Skin If patient denies all HEENT If patient denies all symptoms for this system, check here: ☐ [Show More]

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