Soap Notes Template Week 1

S: Subjective Information the patient or patient representative told you. Initials: T J Age: 28 Gender: Female Height: 170 cm Weight: 90kg BP: 142/82 HR: 86 Temp: 101.1 F SPO2: 99% Pain (1-10): Allergies Medication PenicillinDeveloped a rash when she was a child around 2 years old Food Environment Cats rash, sneezing, trouble breathing requires inhaler. 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): “Scrape on my foot… It looks pretty nasty and the pain is killing me!” Onset: One week ago Location: Plantar surface of right foot Duration: Constant Characteristics: Patient reported tripping on her back steps and scraping the bottom of her foot. Aggravating Factors: Walking and standing on her foot. Relieving Factors: Tramadol for pain and rest. Treatment: Mrs. Jones was seen in the Emergency department three days ago. X-ray was negative for fractures, her wound was cleansed and dressed by staff and she was sent home with a prescription of tramadol for pain. At home Mrs. Jones cleans her wound with soap and water twice a day and peroxide when her foot is “irritated”. Current Medications Medication Dosage Frequency Length of Time Used Reason for Use Albuterol inhaler 90mcg/actuatio n 1-2 puffs 2-3 times a day as needed Since pt was 2.5 years old For asthma exacerbation Ibuprofen 200mg 3 tablets up to 3 times a day as needed Last used 3 weeks ago For menstrual cramping Acetaminophe n 500mg 1-2 tablets twice daily as needed Last used 1 week ago For headaches Tramadol 50mg 3 times daily as needed Three days ago For foot pain 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. Tina was diagnosed with asthma when she was 2.5 years old. She uses an albuterol inhaler for asthma exacerbations, especially around cats. She has been hospitalized several times for her asthma, last reported time was when she was 16 years old. Tina believes she had chicken pox in the second or third grade and was treated with rest at home. She was diagnosed with diabetes at the age of 24. She started her period when she was 11 years old. She believes she is up to date on all immunizations, and reports receiving all immunizations as a child. 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 Tina works as a supervisor at Mid-American Copy and Ship where she has worked since High school. She is in college working towards her bachelor’s degree. She enjoys going out to the clubs and bars with her friends to go dancing. She drinks on occasion at these clubs and reports having 2-3 “rum and diet cokes, no more than 3”. She has never used any tobacco products, vaped or used e-cigarettes. Tina experimented with marijuana when she was 21 and 22 years of age. She was picked on as a child and reported mild anxiety. She reports no current interest in drugs or their use at this time. Tina is active in her church and is very spiritual. She enjoys reading books and watching DVD’s, mostly documentaries. She does not currently exercise daily. Tina lives with her mother and little sister; she reports having a hard time after the death of her father in a motor vehicle accident about a year ago. Tina reports she wears her seat belt. ................................................CONTINUED,.................................................