NR509 Week 3 SOAP Note

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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 ... HR: 82 RR: 16 Temp: 98.9 SPO2: 99% Pain (1-10): 3/10 Allergies Medication: Penicillin—Rash Food: No known allergy Environment: Cats—Asthma exacerbations History of Present Illness (HPI) 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 Chief Complaint (CC): Headache and neck stiffness Onset: Ms. Jones reports experiencing headaches and neck stiffness for approximately 5 days. She reports, 1 week ago, being the restrained, front passenger in her friend’s car when they were rear-ended at low speed. Location: Head and neck Duration: Approximately 5 days Characteristics: Dull ache to the crown and back of head. Stiffness of neck Aggravating Factors: Physical activity Relieving Factors: Tylenol Treatment: NA Current Medications [Show More]

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