Summary NR 509 WEEK 2 SOAP Note Template

NR 509 WEEK 2 SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Ratingwh 0/10 Allergies (and reaction) 170 cm 89 kg 140/ 81 89 20 98.5 97 Medica tion: Penicillin – rash/hives Food: n/a Environment: Cats – Sneezing, itching, asthma attacks, rhinorrhea History of Present Illness (HPI) Chief Complaint (CC) breathing problems, chest tightness, and wheezing 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 2 days ago Location Chest Duration Q 4 hours Characteristics Chest tightness, wheezes, shortness of breath, Aggravating Factors Cats Relieving Factors Inhaler Treatment Proventil Inhaler 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 Proventil Inhaler 90 mcgs BID – TID PRN 25 ½ years Asthma 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. enter text. text. to enter text. 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. PMH - Diabetes, Asthma Current on all immunizations, tetanus booster 1 year ago. Hospitalizations – asthma attacks as a child, foot injury 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. Hobbies – reading, church gatherings, television Family Status – Lives with mother and sister, support available Tobacco – denies Alcohol – occasional, approximately twice a month Illicit drug use – denies 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. Father – Diabetes, High hyperlipidemia, hypertension Mother – hyperlipidemia, hypertension Maternal grandmother – hypertension, hyperlipidemia Maternal grandfather – hypertension, hyperlipidemia