NR 509 WEEK 2 SOAP NOTE. Chamberlain College of Nursing

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SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Ratingwh 0/10 Allergies (and reaction) 170 cm 89 kg 140/ 81 89 20 98.5 97 Medication: Penicillin ... – rash/hives Food: n/a Environment: Cats – Sneezing, itching, asthma attacks, rhinorrhea History of Present Illness (HPI) Chief Complaint (CC) breathing problems, chest tightness, and wheezing 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 Chest Duration Q 4 hours Characteristics Chest tightness, wheezes, shortness of breath, Aggravating Factors Cats Relieving Factors Inhaler Treatment Proventil Inhaler 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 Inhaler 90 mcgs BID – TID PRN 25 ½ years Asthma 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. 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 Click or tap here to enter Click or tap here Click or tap here to enter text. [Show More]

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