NR 509 WEEK 4 SOAP NOTES TEMPLATE

S: Subjective Information the patient or patient representative told you. Initials: BF Age: 58 years old Gender: Male Height: 5’11” Weight: 197lbs BP: 146/90 HR: 104 Temp: 19 SPO2: 98% Pain (1-10): 0/10 Allergies Medication: Codeine—Nausea and vomiting Food: No Known Food Allergies Environment: No Known Environmental Allergies History of Present Illness (HPI) 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 Chief Complaint (CC): Chest Pain/Tightness Onset: 1 month Location: Center of my chest” Duration: “It lasts 2-3 minutes when it happens” Characteristics: “Intermittent tightness and discomfort” Aggravating Factors: Activity, yard work, climbing stairs Relieving Factors: Rest Treatment: No medication treatments, seeking medical treatment today Current Medications Medication Dosage Frequency Length of Time Used Reason for Use Metoprolol 100mg Daily 1 year Hypertension Atorvastatin 20mg Daily at bedtime 1 year High cholesterol Omega 3 Fish Oil 1200mg Twice Daily 1 year High cholesterol 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. Mr. Foster had a Tdap in October 2014 and has received the influenza vaccine for this season. He reports a codeine allergy which caused nausea and vomiting. He denies any history of major illness, hospitalizations, or surgeries. He denied any history of diabetes, coronary artery disease, or peripheral vascular disease. His only reported medical diagnoses are hypertension and high cholesterol. He also reports an approximate weight gain of 20 pounds over the past two years. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Mr. Foster is married and works full-time as an engineer at a civil engineering firm. He denies any history of smoking tobacco or any illicit drugs, including marijuana, cocaine, or heroin. He avoids soda, and reports that his only alcohol intake is 2-3 beers on the weekends “if I’m grilling”. He likes to ride bicycles but reports his last one was stolen. He intends to purchase another bicycle soon so that he can start riding again. Mr. Foster enjoys fishing, watching sports (including his sons body building competitions), and doing repairs on small electronics. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Mr. Foster denies any known family history of stroke, DVT or pulmonary embolism. He reports that his father died of colon cancer at the age of 75 years and had a history of hypertension, hyperlipidemia, obesity. Mr. Fosters mother is 80 years old and has hypertension and diabetes type II. He reports that his brother died at the age of 24 years from a motor vehicle accident. His sister is 52 years old and has hypertension and diabetes type II. Mr. Fosters maternal grandfather died of a heart attack at 54 years of age, and his maternal grandmother died of breast cancer at 65 years of age. Mr. Fosters paternal grandfather died of “old age” at 85 years of age, and his paternal grandmother died of pneumonia at 78 years of age. Mr. Foster has a healthy 26-year-old son and a 19-year-old daughter with asthma. Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Constitutional If patient denies all symptoms for this system, check here: Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Fatigue Weakness Fever/Chills x Weight Changes 20 pound weight gain over 2 year period Trouble Sleeping Night Sweats Other Skin If patient denies all symptoms for this system, check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Itching Rashes Nail Skin Color Other HEENT If patient denies all symptoms for this system, check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Diplopia Eye Pain Eye redness Vision changes Photophobia Eye discharge Eye discharge Earache Tinnitus Vertigo Hearing Changes Hoarseness Sore Throat Congestion Rhinorrhea Other