1
SOAP Note Format – NEURO ASSESSMENT 1/17/18
Patient Information:
TINA JONES
S - subjective
CC: Ms. Jones reports getting into car accident 1 week ago. Has had headaches ever since the
accident.
Pt did not hit head during the accident.
Friend’s car had little dent in back bumper, car that hit Ms. Jones and her friend had a slightly
bigger dent in the front. Stated as “not serious” per patient.
HPI: include all the information regarding the CC using the OLDCART format. If the CC was
“Unintentional weight loss”, the OLDCART for the HPI might look like the following example:
Onset: One week ago, in car accident, HA started a few days after car accident.
Location: Crown of head and back of head, soreness in neck “feels like it goes up into
my head” per pt.
Duration: Headaches last 1-2 hours on average
This study source was downloaded by 100000821441832 from CourseHero.com on 04-04-2021 09:20:16 GMT -05:00
https://www.coursehero.com/file/28019297/SH-
Neuro/
, 2 Characteristics: Dull ache. States pain 3, on 0-10 scale when having a HA. States pain
4/10 at worst. Worst pain stops patient from what she is doing.
Aggravating Factors: None reported. Start spontaneously and then go away.
Relieving Factors: Has been taking Tylenol every day since the accident. Tylenol has
“been helping some”.
Treatment: Tylenol 650 mg (regular strength), 2 regular strength pills.
Current Medications: Tylenol 650mg, 2 tablets PO PRN. Flovent inhaler (does not know dose,
uses twice a day and states she has not missed a dose). Proventil inhaler (does not know dose –
has not needed to use it in almost 8 months).
Allergies: PCN (rash, hives), No seasonal allergies, No food allergies, No allergies to latex.
This study source was downloaded by 100000821441832 from CourseHero.com on 04-04-2021 09:20:16 GMT -05:00
https://www.coursehero.com/file/28019297/SH-
Neuro/
SOAP Note Format – NEURO ASSESSMENT 1/17/18
Patient Information:
TINA JONES
S - subjective
CC: Ms. Jones reports getting into car accident 1 week ago. Has had headaches ever since the
accident.
Pt did not hit head during the accident.
Friend’s car had little dent in back bumper, car that hit Ms. Jones and her friend had a slightly
bigger dent in the front. Stated as “not serious” per patient.
HPI: include all the information regarding the CC using the OLDCART format. If the CC was
“Unintentional weight loss”, the OLDCART for the HPI might look like the following example:
Onset: One week ago, in car accident, HA started a few days after car accident.
Location: Crown of head and back of head, soreness in neck “feels like it goes up into
my head” per pt.
Duration: Headaches last 1-2 hours on average
This study source was downloaded by 100000821441832 from CourseHero.com on 04-04-2021 09:20:16 GMT -05:00
https://www.coursehero.com/file/28019297/SH-
Neuro/
, 2 Characteristics: Dull ache. States pain 3, on 0-10 scale when having a HA. States pain
4/10 at worst. Worst pain stops patient from what she is doing.
Aggravating Factors: None reported. Start spontaneously and then go away.
Relieving Factors: Has been taking Tylenol every day since the accident. Tylenol has
“been helping some”.
Treatment: Tylenol 650 mg (regular strength), 2 regular strength pills.
Current Medications: Tylenol 650mg, 2 tablets PO PRN. Flovent inhaler (does not know dose,
uses twice a day and states she has not missed a dose). Proventil inhaler (does not know dose –
has not needed to use it in almost 8 months).
Allergies: PCN (rash, hives), No seasonal allergies, No food allergies, No allergies to latex.
This study source was downloaded by 100000821441832 from CourseHero.com on 04-04-2021 09:20:16 GMT -05:00
https://www.coursehero.com/file/28019297/SH-
Neuro/
