SOAP Note Format – HEENT

Tina Jones Seen 1 month ago to establish care. S. CC “My throat has been sore…and itchy. And my nose won’t stop running. These symptoms are driving me nuts.” 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: “2-7 days” Location: Throat, 4/10 Duration: Steady weight loss, 3-5 pounds per week Characteristics: “sore” throat…”just clear” discharge from nose…no congestion, no cough…no fever…no change in diet…able to stay hydrated Aggravating Factors: “not that I know of” Relieving Factors: Small, bland meals are better tolerated Treatment: None reported, lozenge Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.  Proventil 2 puffs (pt uses 2-3x/wk)  Lozengers – pt does not know name…every few hours  Advil 3-4 pills PRN during Period Allergies: include medication, food, and environmental allergies separately.  Cats/Dust – sneeze, nose runs, if exposed for too long she starts to wheeze  PCN – when she was little – rash and hives This study source was downloaded by from CourseH on 08-18-2021 06:18:40 GMT -05:00 This study resource was shared vi