Chamberlain College of Nursing NR 590 SOAP Note Week 1| Complete Physical Assessment

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SOAP Note Template Initials: T.F. Age: 24 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 90kg 142/ 82 86 19 101.1F 99% Medication: Penicillin– Rash, hives ... Food: NKA Environment: Dust – asthma exacerbation, runny nose, watery eyes Cats – sneezing, itchy and watery eyes, runny nose chest tightness, wheezing History of Present Illness (HPI) Chief Complaint (CC) Right foot wound with 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 Scraped foot 1 week ago, pain onset two days ago Location Bottom of Right foot Duration Pain is Constant in her right foot, 7/10 Characteristics Foot pain is a throbbing, Sharp pain Aggravating Factors Weight baring Relieving Factors Elevating foot, Tramadol helps for a few hours, decreases pain to 4/10 Treatment Elevating right foot, bandages and cleanses wound, pain medication Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. [Show More]

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