Nursing > SOAP NOTE > Tina jones (T.J) Neurology. SOAP Note Template. Contains Subjective informations; History of Present (All)

Tina jones (T.J) Neurology. SOAP Note Template. Contains Subjective informations; History of Present Illness (HPI); Current Medications; Past Medical History (PMHx); Family History (Fam Hx); Review of Systems (ROS).

Document Content and Description Below

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% 3/10 ... Medication: Penicillin Food: Na Environment: Cats History of Present Illness (HPI) Chief Complaint (CC) 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 Neck and head Duration 2 days Characteristics Head aches throbbing and neck stffness Aggravating Factors Car accidient two days 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 UsedTime Reason for Use Proventil 2 puffs 2-3 time a week Since 2 years old Asthma Tylenol 500 mg 2 tabs every 6 hrs prn headaches Two days Headaches Proair 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. Flexeril 10mg Q4 hrs prn 10days Muscle spasms Metformin 500mg 1 tab q 12 hours indefinately Diabetes Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Solomon, S., Eisnstein, A.(2019). Headache Unit, Montefiore Medical Center, Albert Einstein College of Medicine retrrived from https://www.brainline.org/article/headaches-after-head-injuries Staehler, R., Stiff Neck Causes, Symptoms, and Treatment, (2017). Spine Health retrieved from retrieved from https://www.spinehealth.com/conditions/neck-pain [Show More]

Last updated: 1 week ago

Preview 1 out of 7 pages

Add to cart

Instant download

OR

Reviews( 0 )

Recommended For You

 Nursing> SOAP NOTE > Tina jones (T.J) . SOAP Note week 3 Neuro. Contains Subjective informations; History of Present Illness (HPI); Current Medications; Past Medical History (PMHx); Family History (Fam Hx); Review of Systems (ROS). (All)

Tina jones (T.J) . SOAP Note week 3 Neuro. Contains Subjective informations; History of Present Illness (HPI); Current Medications; Past Medical History (PMHx); Family History (Fam Hx); Review of Systems (ROS).

SOAP Note Template Initials: T.J. Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 88 kg 139/ 87 82 16 98.9 F 99% 3/10 Medication: Penicillin-Rash/Hives Food: No k...

By QuizMaster 2 years ago

SOAP NOTE

$8

5  

 Nursing> SOAP NOTE > Shadow Health NUR 509 SOAP Note – CHEST PAIN. (Chamberlain) Solutions Guide (All)

Shadow Health NUR 509 SOAP Note – CHEST PAIN. (Chamberlain) Solutions Guide

Patient Information: Brian Foster, 58 yo Male. Presenting with recent episode of chest pain. S. CC: Patient states intermittent chest pain that is tight and uncomfortable. HPI: Onset: Earlier in...

By Academia1434 2 years ago

SOAP NOTE

$12.5

1  

 Nursing> SOAP NOTE > SOAP NOTE 2 Emily Green (I-Human Patient) Case 2021| Ultimate Guide for Grade A+ (All)

SOAP NOTE 2 Emily Green (I-Human Patient) Case 2021| Ultimate Guide for Grade A+

SOAP NOTE 2 Emily Green (I-Human Patient) Case 2021| Ultimate Guide for Grade A+| A 22-year-old female college student presented to the clinic setting today unaccompanied. The patient states she has...

By Quiz Merchant 1 year ago

SOAP NOTE

$7

7  

 Nursing> SOAP NOTE > Walden University - NURSING: NURS6512 Health Assessment Week 9 discussion: SOAP NOTE Case Study #3. Graded A. SOAP NOTE (All)

Walden University - NURSING: NURS6512 Health Assessment Week 9 discussion: SOAP NOTE Case Study #3. Graded A. SOAP NOTE

SOAP NOTE Case Study #3 Patient Initials: __MH___ Age: _33____ Gender: __F____ SUBJECTIVE DATA: Chief Complaint (CC): Drooping on the right side of face History of Present Illness (H...

By QuizMaster 2 years ago

SOAP NOTE

$9

0  

 Nursing> SOAP NOTE > Brian Foster SOAP v2 SHADOW HEALTH LATEST HEALTH ASSESSMENT 100% CORRECT (All)

Brian Foster SOAP v2 SHADOW HEALTH LATEST HEALTH ASSESSMENT 100% CORRECT

Brian Foster SOAP v2HEALTH ASSESSMENT Brian Foster is a 58-year-old man experiencing a change of status. Students determine the seriousness of his complaint and take a relevant health history. Studen...

By STUDY-GUIDENOTES 1 year ago

SOAP NOTE

$10

2  

 Nursing> SOAP NOTE > Walden University - NURSING: NURS6512 Health Assessment Week 8 discussion: SOAP NOTE Case Study Ankle Pain. Graded A. SOAP NOTE (All)

Walden University - NURSING: NURS6512 Health Assessment Week 8 discussion: SOAP NOTE Case Study Ankle Pain. Graded A. SOAP NOTE

SOAP NOTE Ankle Pain Patient Initials: __MH___ Age: _46____ Gender: __F____ SUBJECTIVE DATA: Chief Complaint (CC): Ankle pain bilaterally History of Present Illness (HPI): MH is a 46-y...

By QuizMaster 2 years ago

SOAP NOTE

$10.5

1  

 Nursing> SOAP NOTE > NR509-SOAP-NOTE -Brian Foster" SHADOW HEALTH 2021 (All)

NR509-SOAP-NOTE -Brian Foster" SHADOW HEALTH 2021

NR509-SOAP-NOTE -Brian Foster" SHADOW HEALTH 2021

By Verified A+ 1 year ago

SOAP NOTE

$12

0  

 Nursing> SOAP NOTE > (solved) iHuman SOAP Damian Henderson Abd Pain. (All)

(solved) iHuman SOAP Damian Henderson Abd Pain.

iHuman SOAP Damian Henderson Abd Pain CC: “abdominal painx 8 hrs” HPI: Mr Henderson is a 22 yo male who presents with diffuse non-radiating umbilical pain 6/10 which started 8 hrs ago. Pain was rep...

By Homework provider 1 year ago

SOAP NOTE

$8

0  

 Nursing> SOAP NOTE > SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent (All)

SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent

SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent SUBJECTIVE: Chief complaint (CC): “I came in because I'm required to have a recent physical exam for the health...

By montanagreys 1 year ago

SOAP NOTE

$13.5

1  

 Nursing> SOAP NOTE > Tina jones (T.J). SOAP Note Template. Contains Subjective informations; History of Present Illness (HPI); Current Medications; Past Medical History (PMHx); Family History (Fam Hx); Review of Systems (ROS); (All)

Tina jones (T.J). SOAP Note Template. Contains Subjective informations; History of Present Illness (HPI); Current Medications; Past Medical History (PMHx); Family History (Fam Hx); Review of Systems (ROS);

SOAP Note Template Initials: T.J Age: 28 years old Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88 kg 139/ 87 82 16 98.9 99% Choose an item. Medication: Penicillin (Caus...

By QuizMaster 2 years ago

SOAP NOTE

$8

1  

SOAP NOTE

$8.50

Add to cart

Instant download

OR

Can't Find what you want?

PLACE CUSTOM WRITING ORDER
102
0

Document information


Connected school, study & course



About the document


Uploaded

2 years ago

Number of pages

7

Written in

All

Type

SOAP NOTE

Seller


QuizMaster

Member since 3 years ago

997 Documents Sold


Additional information

This document has been written for:

Course

Nursing

Paper Category

SOAP NOTE

Uploaded

2 years ago

Downloads

 0

Views

 102

THE BEST STUDY GUIDES

Avoid resits and achieve higher grades with the best study guides, textbook notes, and class notes written by your fellow students

Avoid examination resits

Your fellow students know the appropriate material to use to deliver high quality content. With this great service and assistance from fellow students, you can become well prepared and avoid having to resits exams.

Get the best grades

Your fellow student knows the best materials to research on and use. This guarantee you the best grades in your examination. Your fellow students use high quality materials, textbooks and notes to ensure high quality

Earn from your notes

Get paid by selling your notes and study materials to other students. Earn alot of cash and help other students in study by providing them with appropriate and high quality study materials.

WHAT STUDENTS SAY ABOUT US


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·