Summary NR 509 WEEK 5 SOAP Note Template

NR 509 WEEK 5 SOAP Note Template Initials: E.P. Age: 78 years old Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 62 inches 54.43 kg 110/ 70 92 16 37.0 C 99% Medication: No known drug allergies Food: No known food allergies Environment: Reports latex allergy-contact dermatitis History of Present Illness (HPI) Chief Complaint (CC) “Pain in my belly” and “I’m having difficulty going to the bathroom” 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 Patient reports abdominal discomfort that started 5 days ago Location Lower abdomen, PT states “low in my belly” Duration Constant discomfort for 5 days and has gradually worsened over the last 2-3 days Characteristics Constant “dull, crampy” abdominal pain that stays in one place. At onset of pain patient reported 3 out of 10. Patient currently rates pain 6 out of 10. Experiencing bloating and increased flatulence. Aggravating Factors Moving around the house, gardening, eating Relieving Factors Resting, and trying “not to move too much” which provides some relief but can still tell the pain is present Treatment Small sips of warm water without relief, no medications taken for symptoms 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 Time Used Reason for Use Accupril (Quinapril) 10 mg (1 tablet) One tablet by mouth daily in the morning with or without food 24 years For the treatment of hypertension 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. 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. 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. 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. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.