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

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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 S: Subjective Information the patient or patient representative told you This study source was downloaded by 100000831988016 from CourseHero.com on 04-11-2022 07:21:21 GMT -05:00 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. Single Denies tobacco use Use to use illicit drugs-Marijuanna- last used 3 years ago Social alcohol use (2 times a month) 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. Mother- HTN, Hyperlipidemia Father- HTN, Hyperlipidemia, Type 2 Diabetic Paternal Grandmother- HTN, Hyperlipidemia 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 Skin HEENT ☐Fatigue Click or tap here to enter text. ☐Weakness Click or tap here to enter text. ☐Fever/Chills Click or tap here to enter text. ☐Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☐Trouble Sleeping Click or tap here to enter text. ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☐Skin Color Changes Click or tap here to enter text. ☒Other: Wound to right plantar aspect of foot ☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text. ☐Earache Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text. ☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☐Sore Throat Click or tap here to enter text. ☐Congestion Click or tap here to enter text. ☐Rhinorrhea Click or tap here to enter text. ☐Other: Click or tap here to enter text. This study source was downloaded by 100000831988016 from CourseHero.com on 04-11-2022 07:21:21 GMT -05:00 Respiratory Neuro Cardiovascular ☐Cough Click or tap here to enter text. ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☐Sputum Production ☒Other: Asthma- induced when around cats ☐Syncope or Lightheadedness Click or tap here to enter text. ☐Headache Click or tap here to enter text. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Chest pain Click or tap here to enter text. ☐SOB Click or tap here to enter text. ☐Exercise Intolerance Click or tap here to enter text. ☐Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs Click or tap here to enter text. ☐Palpitations Click or tap here to enter text. ☐Faintness Click or tap here to enter text. ☐OC Changes Click or tap here to enter text. ☐Claudications Click or tap here to enter text. ☐PND Click or tap here to enter text. ☒Other: elevated blood pressure- family history MSK GI GU PSYCH ☒Pain 7/10 at right foot ☐Stiffness Click or tap here to enter text. ☐Crepitus Click or tap here to enter text. ☒Swelling at wound on right plantar aspect of foot ☐Limited ROM ☒Redness at wound on right plantar aspect of foot ☐Misalignment Click or tap here to enter text. ☒Other: unable to bear weight to right foot ☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Blood in Stool Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. ☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to enter text. ☐Hematuria Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Stress Click or tap here to enter text. ☐Anxiety Click or tap here to enter text. ☐Depression Click or tap here to enter text. ☐Suicidal/Homicidal Ideation Click or tap here to enter text. ☐Memory Deficits Click or tap here to enter text. ☐Mood Changes Click or tap here to enter text. ☐Trouble Concentrating Click or tap here to enter text. This study source was downloaded by 100000831988016 from CourseHero.com on 04-11-2022 07:21:21 GMT -05:00 ☐Excessive Flatus Click or tap here [Show More]

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