Tina Jones Week 1 NR509 SOAP NOTES TEMPLATE

Tina Jones Week 1 NR509 SOAP NOTES TEMPLATE Tina Jones Week 1 NR509 SOAP NOTES TEMPLATE S: Subjective Information the patient or patient representative told you. Initials: T.J Age: 28 Gender: Female Height: 170cm Weight: 90kg BP: 142/82 HR: 86 Temp: 101.1 SPO2: 99% Pain (1-10): 7/10 Allergies Medication Penicillin = Rash/Hives Food No Known Allergies Environment Cat Dander & Dust = Sneezing, Itchy eyes, Wheezing 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): “I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it looking pretty nasty. And the pain is killing me!” Onset: 7 days prior to exam Location: Plantar surface of right foot Duration: Initial injury a week ago with worsening pain over the past 2 days Characteristics: Throbbing and sharp pain when weight bearing. The wound has white/offwhite oozing discharge. Aggravating Factors: Weight-bearing Relieving Factors: Pain medication, elevation, and rest Treatment: Tramadol for the pain and Ms. Jones has been cleansing the wound twice a day, applying Neosporin, and changing the bandage twice a day Current Medications Medication Dosage Frequency Length of Time Used Reason for Use Acetaminophe n 500mg PRN As needed Headaches Ibuprofen 200mg PRN 3 times a day As needed Menstrual Cramps Tramadol 50 mg 3 times a day 2 days Right Foot Pain Albuterol Inhaler 90mcg/spra y As needed 2-3 times a day every 4 hours As needed Wheezing / Asthma Metformin Unknown 1 pill twice a day Took 3 years ago Diabetes Neosporin 1 application As needed Twice a day As needed 1 week Wound Infection 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. Last tetanus booster 1 year ago Denies any recent or past surgeries or illness She has asthma. Last hospitalization at 16 hears old for asthma Denies being intubated during these hospitalizations Asthma diagnosed at age 2 ½ Uncontrolled and unmonitored Type 2 Diabetes Mellitus diagnosed at age 24 and an open foot wound sustained one week ago when she tripped on steps barefoot Unexplained weight loss of ten pounds and has been excessively thirsty and experiencing nocturia Menarche at age 11 with irregular and heavy periods. Last menstrual cycle was 3 week ago Sexually active with men only, last tested for STDs 4 years ago, never tested for HIV 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 Occupation: Supervisor at Mid-American Copy & Ship. Working there since high school Education: College student majoring in accounting Hobbies: Enjoys watching tv, reading books, and going to talks at her church. Very active in church and with family, goes out occasionally with friends dancing, and enjoys bible study and volunteering with her church Family: Lives with mother and sister after her father passed away she moved back home to help with finances Tobacco and Alcohol use: Denies smoking cigarettes and other illicit drugs currently Smoked marijuana at 20/21 years old, does not currently use Drinks diet coke soda and alcohol couple of times a month when going out with friends Currently single, not sexually active and not taking contraceptives but used birth control while sexually active with previous partner Never been married or pregnant Total of three partners Non-compliant with diabetic medications. Has not used in 3 years. Does not monitor blood glucose daily, last glucose check during ER visit 1 week ago. Does not check blood pressure regularly. Not currently sexually active, last used oral contraceptives a couple of years ago. Last pap smear 4 years ago. 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. Mother = 55 yo Living - Hypertension & Hyperlipidemia Father = Deceased- died in car accident at 58 years old, Type II diabetes, Hypertension, High Cholesterol Paternal Grandfather = Deceased - colon cancer, Hypertension, High Cholesterol, Type II diabetes Paternal Grandmother = Living - Hypertension, High Cholesterol Maternal Grandfather = Deceased - died of a heart attack, Hypertension, High Cholesterol Maternal Grandmother = Deceased - died of a stroke 5 years ago, Hypertension, High Cholesterol Sister = Living – Asthma Brother = Living – Overweight like most of her family Paternal uncle = alcoholic 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 Tired and cranky recently Weakness Fever/Chills 101.1 F during assessment Weight Changes Lost 10lb this month. Unknown cause Trouble Sleeping Night Sweats Other Skin If patient denies all symptoms for this system, check here: Check the box next to each reported symptom and provide additional details.