NR 509 Chest Pain SOAP Note

CHEST PAIN - SOAP Note. Case study Última actualización de este documento:   hace

SOAP Note Template Initials: B. F. Age: 58 Gender: M Height Weight BP HR RR Temp SPO2 Pain Allergies 180.34 cm 197 146/90 104 19 36.7 C 98% 0/10 Medication: Codeine (causes nausea and vomiting) Food: NKA Environment: NKA History of Present Illness (HPI) Chief Complaint (CC) Chest Pain 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 compl...