Summary NR 509 WEEK 6 SOAP Note Template

NR 509 WEEK 6 SOAP Note Template Initials: D.R. Age: 8 years old Gender: Male Height Weight BP HR RR Temp SPO2 Pain Allergies 127 cm 40.9 kg 120/ 76 100 28 37.2 C 96% Medication: No known drug allergies Food: No known food allergies Environment: No known environmental allergies History of Present Illness (HPI) Chief Complaint (CC) “I have been coughing a lot” 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 Started 5 days ago Location Throat and right ear Duration Throat pain x5 days and ear pain x1 day Characteristics Productive cough every couple of minutes with clear sputum. Describes his cough as “gurgly and watery” Cough keeps the patient up at night. Cough is accompanied by a sore throat, right ear pain and worsening rhinorrhea with clear discharge Aggravating Factors Worsens at 2100 every night. Exposed to second hand smoke by his father who smokes a cigar in the house multiple times a week. Relieving Factors Temporary relief with “spoonful of purple cough medicine” Treatment Patient’s mother has been giving the patient a “spoonful of purple cough medicine” with temporary relief. The patient has tried resting and drinking water without relief, the cough “stays the same” 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 Antitussive “One spoonful” by mouth with or without food As needed for cough per age/weight dosage on manufacturer package 1 day Cough Multivitamin One gummy by mouth with or without food Daily Unknown Supplement 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.