NURS 612 ASSIGNMENT WEEK 5 SOAP NOTE RESPIRATORY DOCUMENTATION (1).

NURS 612 ASSIGNMENT WEEK 5 SOAP NOTE RESPIRATORY DOCUMENTATION (1).S.O.A.P. Note Template CASE ID# _Week 5 Assignment _____ Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan) Lani Doloroso Chief Complaint What brought you here today…(eg. headache) Cough History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Pleasant Caucasian female looking stated age presented at the clinic today with a two-day history of cough. She stated that initially the cough was non-productive but now she “can tell” that she has been coughing up some mucous. She is not able to provide a description of the sputum. She states that she has some congestion in her chest but denies any sinus congestion. She doesn’t have a runny nose and states that she has had “some chills, maybe a fever, but I didn’t take my temperature.” She is fatigued and run-down feeling but has no body aches. She has had some increasing shortness of breath on exertion and c/o “having a harder time catching my breath when walking up the stairs.” She reports hearing her breathing like a wheezing when she is lying down at night. She does have seasonal allergies but states that this is not the time of the year when they affect her, and this is different than that. She does not have any asthma, other respiratory conditions or chest pains. No one around her at home or work is sick. She doesn’t have any environmental exposure to chemicals or toxins. She has not tried any over the counter medications for her symptoms. Location Duration Character Aggravating/associated factors Relieving factors Temporal factors – other things going on Severity Past Medical History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications Adult Illness: No data. Childhood Illness: No data. Immunization: Received influenza this year Surgeries: No data. Allergies: seasonal allergies Current Medications: None Family History Include Parents, siblings; grandparents if applicable/known, cause of death, age, pertinent medical illnesses Family History: No data. Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known Education – No data. Marital status - No data. Occupation - No data. Alcohol/drug use - No data. Smoking status - previous smoker, stopped smoking approximately 20 years ago Sexual history - No data. Exercise - No data. Nutrition - No data. Religious preference - No data. Review of Systems General: Positive for chills. Positive for fatigue. Positive for cough. Hair, Skin, & Nails: Positive for chills at night and have a little flushed. Head: Negative for congestion. Negative sinus problem Neck: No data. Eyes: No data. Ears: Negative for discharge. Negative for pain. Negative for hearing loss. Nose: Negative for nasal congestion or nasal drainage Mouth & Throat: No data. Cardiovascular: Negative for pain in the chest.