NURS 5334 Adult SOAP example posted SOAP Note Form Adult Management I
SOAP Note Form Adult Management ISOAP Note Form Adult Management I S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx: D. T., 02/12/1975, Female, Reliable historian Paternal Lung Cancer, Maternal Diabetes Personal/Social Chief Complaint/RFE: Hx: Divorced, lives at home with one teenage child, no history of tobacco, ETOH, or illicit drug use Cough, congestion, sore throat, flu two weeks ago Hx Present Illness: (7 Variables but do not list as such) Patient was diagnosed with the flu two weeks ago and treated with Tamiflu. Her fever and body aches have subsided, but her cough and nasal congestion remain, and she developed a sore throat yesterday. Her symptoms are concentrated in her head, neck, and chest. Her symptoms are worse at night and in the morning. She has a dull pain in her throat that worsens with swallowing. She rates her throat pain while swallowing a 5/10. Pt has not taken her temperature. Her symptoms improve with rest and OTC cold and flu medicine. Pt says that she “gets a cold about once a winter, but this has gone on a lot longer.” Pt denies any other symptoms. CURRENT HEALTH Medications: Dayquil (acetaminophen 325mg, dextrometh
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