NR509 Week 2 SOAP Note – Johns Hopkins University Nursing

NR509 Week 2 SOAP Note – Johns Hopkins University Nursing Laatste update van het document:   geleden

S: Subjective Information the patient or patient representative told you. Initials: JT Age: 28 years Gender: Female Height: 170cm Weight: 89kg BP: 140/81 HR: 89 Temp: 98.5 SPO2: 97% Pain (1-10): 0 Allergies Medication: Penicillin Food: No known allergy Environment: Cats 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 ...