NR 509 WEEK 4 SOAP NOTE
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
a
Initials: BF Age: 58 Gender: Male
vi
Height Weight BP HR RR Temp SPO2 Pain Allergies
5’ 11 197lbs 146/ 104 19 36.7C 98% Medication: Codeine : reports causes nausea and vomiting
d
90 Food: none
e
Environment: none
ar
History of Present Illness (HPI)
Chief Complaint (CC) Chest pain CC is a BRIEF statement identifying
sh
Onset While doing strenuous acitivties, earlier this month. why the patient is here - in the
Location Middle of chest. Does not radiate. patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration 3 episodes for the past month. Each episode lasts for a couple of minutes.
as
days”. Sometimes a patient has more
Characteristics Chest tightness in the middle of chest without radiation. than one complaint. For example: If
w
the patient presents with cough and
Aggravating Factors Yard work and climbing stairs at work. sore throat, identify which is the CC
Relieving Factors Taking a break or sat down to rest. and which may be an associated
m e
Treatment Reports no treatment uses symptom
Medication co rc
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Length of Time
o. ou
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Atorvastatin (Lipitor) PO 10mg Daily at HS One year High Cholesterol
er res
Metoprolol (Lopressor) PO 100mg Daily One year High blood pressure
Omega-3 Fish Oil PO 1200mg Daily Unable to Does not respond when asked why.
respond ( last
dose taken this
eH y
AM)
rs ud
Tylenol “Whatever the bottle PRN PRN For Headache
recommends for an
adult”
t
ss
Ibuprofen “Whatever the bottle PRN PRN Varioius aches and pains
recommends for an
adult”
hi
, 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.
3 episodes of 5/10 chest pain with physical activity, that resolved with rest after 2 min. Reports no shortness of breath. History of hypertension and
a
hyperlipidemia. Reports Stress test 4 mo ago: normal. EKG: NSR with no ST changes. Last annual exam by PCP: 3 months ago. Reports never
hospitalized. Reports no surgical history. Threw out back few years ago and took codeine, but reports allergy to codeine. Unable to recall last
vi
Pneumovax vaccine. Tdap: last on 10/2014. Influenza : received this flu season. Regular caffeine intake 1-2 cups daily.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
d
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
e
Patient is married, lives with wife and daughter. Son lives in town. Patient is a
ar
Civil Engineer (denies working out in the field) Goes over work proposals. Denies chemical exposure. Hobbies include: fishing, sports, going to see
son’s body building competitions. Family dynamic is great. Low stress. Denies cigarette smoking.Denies tobacco use. Denies current illicit drug
sh
use. Reports history of cocaine use 30 yrs ago. Reports drinking 1-2 cups coffee daily. Reports 2-3 alcohol drinks per weekend (typically drinks 2-
3beers in one sitting). Denies hx or current suicidal ideation. Denies Depression. Denies regular exercise.
as
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
w
pertinent.
m e
Mother 80 y.o.(living)- Type 2 Diabetes and hypertension
Spouse (Maria) 51 y.o. : Denies illnesses
co rc
Father-Deceased at 75y.o. from colon cancer. Hx obesity, hypertention, and hyperlipidemia
Son (Sam) 26y.o. : reports is healthy, is a competitive body builder
o. ou
Daughter(Allie) 19y.o. : Asthma
Sister: 52 y.o.living- Type 2 Diabetes and hypertention
er res
Brother: deceased at 24y.o. from a car accident.
Paternal grandpa- died at 85y.o. unknown
Paternal grandma- died at 78 y.o from pneumonia.
Maternal grandpa- died at 54 from a heart attack.
eH y
Maternal grandma- died at 65 from breast cancer.
rs udt
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
ss
symptom and provide additional details.
Constitutional Skin HEENT
hi
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
a
Initials: BF Age: 58 Gender: Male
vi
Height Weight BP HR RR Temp SPO2 Pain Allergies
5’ 11 197lbs 146/ 104 19 36.7C 98% Medication: Codeine : reports causes nausea and vomiting
d
90 Food: none
e
Environment: none
ar
History of Present Illness (HPI)
Chief Complaint (CC) Chest pain CC is a BRIEF statement identifying
sh
Onset While doing strenuous acitivties, earlier this month. why the patient is here - in the
Location Middle of chest. Does not radiate. patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration 3 episodes for the past month. Each episode lasts for a couple of minutes.
as
days”. Sometimes a patient has more
Characteristics Chest tightness in the middle of chest without radiation. than one complaint. For example: If
w
the patient presents with cough and
Aggravating Factors Yard work and climbing stairs at work. sore throat, identify which is the CC
Relieving Factors Taking a break or sat down to rest. and which may be an associated
m e
Treatment Reports no treatment uses symptom
Medication co rc
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Length of Time
o. ou
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Atorvastatin (Lipitor) PO 10mg Daily at HS One year High Cholesterol
er res
Metoprolol (Lopressor) PO 100mg Daily One year High blood pressure
Omega-3 Fish Oil PO 1200mg Daily Unable to Does not respond when asked why.
respond ( last
dose taken this
eH y
AM)
rs ud
Tylenol “Whatever the bottle PRN PRN For Headache
recommends for an
adult”
t
ss
Ibuprofen “Whatever the bottle PRN PRN Varioius aches and pains
recommends for an
adult”
hi
, 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.
3 episodes of 5/10 chest pain with physical activity, that resolved with rest after 2 min. Reports no shortness of breath. History of hypertension and
a
hyperlipidemia. Reports Stress test 4 mo ago: normal. EKG: NSR with no ST changes. Last annual exam by PCP: 3 months ago. Reports never
hospitalized. Reports no surgical history. Threw out back few years ago and took codeine, but reports allergy to codeine. Unable to recall last
vi
Pneumovax vaccine. Tdap: last on 10/2014. Influenza : received this flu season. Regular caffeine intake 1-2 cups daily.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
d
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
e
Patient is married, lives with wife and daughter. Son lives in town. Patient is a
ar
Civil Engineer (denies working out in the field) Goes over work proposals. Denies chemical exposure. Hobbies include: fishing, sports, going to see
son’s body building competitions. Family dynamic is great. Low stress. Denies cigarette smoking.Denies tobacco use. Denies current illicit drug
sh
use. Reports history of cocaine use 30 yrs ago. Reports drinking 1-2 cups coffee daily. Reports 2-3 alcohol drinks per weekend (typically drinks 2-
3beers in one sitting). Denies hx or current suicidal ideation. Denies Depression. Denies regular exercise.
as
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
w
pertinent.
m e
Mother 80 y.o.(living)- Type 2 Diabetes and hypertension
Spouse (Maria) 51 y.o. : Denies illnesses
co rc
Father-Deceased at 75y.o. from colon cancer. Hx obesity, hypertention, and hyperlipidemia
Son (Sam) 26y.o. : reports is healthy, is a competitive body builder
o. ou
Daughter(Allie) 19y.o. : Asthma
Sister: 52 y.o.living- Type 2 Diabetes and hypertention
er res
Brother: deceased at 24y.o. from a car accident.
Paternal grandpa- died at 85y.o. unknown
Paternal grandma- died at 78 y.o from pneumonia.
Maternal grandpa- died at 54 from a heart attack.
eH y
Maternal grandma- died at 65 from breast cancer.
rs udt
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
ss
symptom and provide additional details.
Constitutional Skin HEENT
hi
