Chamberlain College of Nursing Tina Jones Neurology (3} new

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SOAP Note Template Initials: TJ/ address 9647 Jeffers St. Spring Hill Fl 34606 Age: 28 Gender: female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 88 kg 139/ 87 82 16 98.9 99% Medic... ation: Penicillin Food: Na Environment: Cats History of Present Illness (HPI) Chief Complaint (CC) “Fender bender headaches and neck stiffness” 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 2 days ago Location Chrown and back of head Duration 5 days Characteristics “Dull ache” Aggravating Factors Car accidient one week ago Relieving Factors Tylenol Treatment Tylenol for pain 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 2 puffs q6 hours as needed shortness of breath Since 2 years old Asthma Tylenol 325 mg 1-2 tabs every 6 hrs prn headaches Five days Headaches 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. 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. 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, [Show More]

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