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NR509 Week 1 SOAP Note
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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): Acute pain of right foot Onset: 7 days prior to exam Location: Right foot, plantar aspect Duration: 1 week Characteristics: Throbbing, stabbing Aggravating Factors: Bearing weight, ambulation Relieving Factors: Rest, elevation, pain medication Treatment: Tramadol Current Medications
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