NR509 Shadow Health SOAP Note Template NR509 Shadow Health SOAP Note Template SOAP Note Template S: Subjective Information the patient or patient representative told you SOAP Note Template CLASSROOM

NR509 Shadow Health SOAP Note Template NR509 Shadow Health SOAP Note Template SOAP Note Template S: Subjective Information the patient or patient representative told you SOAP Note Template CLASSROOM Initials: Click or tap here to enter text.Age: Click or tap here to enter text.Gender: Click or tap here to enter text.HeightWeightBPHRRRTempSPO2PainAlergiesClick 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.Choose an item.Medication: Click or tap here to enter text. Food: Click or tap here to enter text. Environment: Click or tap here to enter text. History of Present Ilness (HPI) NR509 Shadow Health SOAP Note TemplateChief Complaint (CC)Click or tap here to enter text.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 symptomOnsetClick or tap here to enter text.LocationClick or tap here to enter text.DurationClick or tap here to enter text.CharacteristicsClick or tap here to enter text.Aggravating FactorsClick or tap here to enter text.Relieving FactorsClick or tap here to enter text.TreatmentClick or tap here to enter text.Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Medication (Rx, OTC, or Homeopathic) DosageFrequencyLength of Time UsedReason for UseClick 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 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. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for a l adults), past major i lnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Click or tap here to enter text. 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 a l the time or working smoke detectors in the house. Click or tap here to enter text. Family History (Fam Hx) – Includes but not limited to i lnesses with possible genetic predisposition, contagious or chronic i lnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Click or tap here to enter text. CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM Review of Systems (ROS): Address al body systems that may help rule in or out a di ferential diagnosis Check the box next to each positive symptom and provide additional details.ConstitutionalSkinHEENT☐Fatigue Click or tap here to enter text. ☐Weakness Click or tap here to enter text. ☐Fever/Chi ls Click or tap here to enter text. ☐Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☐Trouble Sleeping Click or tap here to enter text. ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☐Skin Color Changes Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text. ☐Earache Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text. ☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☐Sore Throat Click or tap here to enter text. ☐Congestion Click or tap here to enter text. ☐Rhinorrhea Click or tap here to enter text. ☐Other: CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM Click or tap here to enter text. RespiratoryNeuroCardiovascular☐Cough Click or tap here to enter text. ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☐Sputum Production Choose an item. Choose an item. Choose an item. ☐Other: Click or tap here to enter text. ☐Syncope or Lightheadedness Click or tap here to enter text. ☐Headache Click or tap here to enter text. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes Choose an item. ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Chest pain Click or tap here to enter text. ☐SOB Click or tap here to enter text. ☐Exercise Intolerance Click or tap here to enter text. ☐Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs Click or tap here to enter text. ☐Palpitations Click or tap here to enter text. ☐Faintness Click or tap here to enter text. ☐OC Changes Click or tap here to enter text. ☐Claudications Click or tap here to enter text. ☐PND Click or tap here to enter text. ☐Other: Click or tap here to enter text. CLASSROOM CLASSROOM CLASSROOM