NUR 509SH Neurocase SOAP Note Format – NEURO ASSESSMENT

S - subjective CC: Ms. Jones reports getting into car accident 1 week ago. Has had headaches ever since the accident. Pt did not hit head during the accident. Friend’s car had little dent in back bumper, car that hit Ms. Jones and her friend had a slightly bigger dent in the front. Stated as “not serious” per patient. HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example: Onset: One week ago, in car accident, HA started a few days after car accident. Location: Crown of head and back of head, soreness in neck “feels like it goes up into my head” per pt. Duration: Headaches last 1-2 hours on average Characteristics: Dull ache. States pain 3, on 0-10 scale when having a HA. States pain 4/10 at worst. Worst pain stops patient from what she is doing. Aggravating Factors: None reported. Start spontaneously and then go away. Relieving Factors: Has been taking Tylenol every day since the accident. Tylenol has “been helping some”. Treatment: Tylenol 650 mg (regular strength), 2 regular strength pills