NR 509 SOAP Note Template Tina Jones week 3.

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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 [Show More]

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