*NURSING > SOAP NOTE > SOAP Note Template (All)

SOAP Note Template

Document Content and Description Below

☒Fatigue “ tired, because my cough keeps me up at night” ☐Weakness denies ☐Fever/Chills denies ☐Weight Gain denies ☐Weight Loss denies ☒Trouble Sleeping “cough has made it hard to fa... ll asleep” ☐Night Sweats denies ☐Other: Click or tap here to enter text. ☐Itching denies ☐Rashes denies ☐Nail Changes denies ☐Skin Color Changes d ☒Other: Has dry skin on legs. THINK 3 A’s Allergy,asthma,atopic dermatitis. ☐Diplopia denies ☐Eye Pain denies ☐Eye redness denies ☐Vision changes denies ☐Photophobia denies ☐Eye discharge denies ☒Earache Right ear pain started 1 day ago. ☐Tinnitus denies ☐Epistaxis denies ☐Vertigo denies ☐Hearing Changes denies ☐Hoarseness denies ☐Oral Ulcers denies ☒Sore Throat started 2 out of 10 pain, cobblestoning and erythema. ☐Congestion denies ☒Rhinorrhea reports always a little runny but the clear runny nose worse the last 5 days. ☒Other: Right ear canal erythema, tympanic membrane- pearly gray, intact, no bulge. Respiratory Neuro Cardiovascular ☒Cough reports productive cough, started 5days ago ☐Hemoptysis denies ☐Dyspnea denies ☐Wheezing denies ☐Pain on Inspiration denies ☐Sputum Production ☐Other: clear thin sputum ☐Syncope or Lightheadedness denies ☐Headache denies ☐Numbness denies ☐Tingling Click or tap denies here to enter text. ☐Sensation Changes ☐Speech Deficits denies ☐Other: Click or tap here to enter text. ☐Chest pain denies ☐SOB denies ☐Exercise Intolerance denies ☐Orthopnea denies ☐Edema denies ☐Murmurs denies ☐Palpitations denies ☐Faintness denies ☐OC Changes denies ☐Claudications denies ☐PND denies ☐Other: Click or tap here to enter text. MSK GI GU PSYCH ☐Pain denies ☐Stiffness denies ☐Crepitus unable to assess ☐Swelling denies ☐Nausea/Vomiting denies ☒Dysphasia states swallows okay but throat is sore. ☐Diarrhea denies ☐Urgency denies ☐Dysuria denies ☐Burning denies ☐Hematuria denies ☐Stress denies ☐Anxiety denies ☐Depression denies ☐Suicidal [Show More]

Last updated: 1 year ago

Preview 1 out of 9 pages

Reviews( 0 )

$10.00

Add to cart

Instant download

Can't find what you want? Try our AI powered Search

OR

GET ASSIGNMENT HELP
52
0

Document information


Connected school, study & course


About the document


Uploaded On

Apr 18, 2021

Number of pages

9

Written in

Seller


seller-icon
solution001

Member since 3 years

8 Documents Sold


Additional information

This document has been written for:

Uploaded

Apr 18, 2021

Downloads

 0

Views

 52

Document Keyword Tags

Recommended For You


$10.00
What is Browsegrades

In Browsegrades, a student can earn by offering help to other student. Students can help other students with materials by upploading their notes and earn money.

We are here to help

We're available through e-mail, Twitter, Facebook, and live chat.
 FAQ
 Questions? Leave a message!

Follow us on
 Twitter

Copyright © Browsegrades · High quality services·