NURS 623 12.2 S.O.A.P. Note Template

NURS 623 12.2 S.O.A.P. Note TemplateCase ID#: Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan) Basic Information Patient demographics Assignment 12.2 SOAP Note Subjective History Chief Complaint What brought you here today…(such as a headache) Back pain History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS (Onset, Location, Duration, Character, Aggravating/associated factors, Relieving factors, Temporal factors – other things going on, Severity) in paragraph form A 42-year-old obese female presents with complaints of lower back pain for the past week that feels worse today. The pain is constant and intermittently radiates down her left leg. It is not improved with ibuprofen. She works as a grocery store clerk. Past Medical History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications Past medical history: None Past surgical history: None Patient is current in her immunizations