NR509 SOAP Note Template week 3

S: Subjective Information the patient or patient representative told you Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88kg 139/ 82 16 98.9 F 99 Medication: Pencillin- Rash, hives 87 Food: None Environment: Cats-Exacerbation of asthma, runny nose History of Present Illness (HPI) Chief Complaint (CC) Headache, neck pain CC is a BRIEF statement identifying Onset 1 week ago, following a car accident why the patient is here - in the Location Crown and back of head, both sides of neck patient’s own words - for instance "headache", NOT "bad headache for 3 Duration 5 days days”. Sometimes a patient has more Characteristics Head-dull ache, Neck-stiff and sore than one complaint. For example: If the patient presents with cough and Aggravating Factors Nothing, comes on suddenly sore throat, identify which is the CC Relieving Factors Tylenol and rest and which may be an associated Treatment Tyenol 2 tabs and rest symptom Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication Length of Time Dosage Frequency Reason for Use (Rx, OTC, or Homeopathic) Used Tylenol Unsure “2 Regular Once 5 days Headaches & Neck pain strength tabs” Flovent 2 Puffs Twice daily 8 Months Asthma Proventil 2 Puffs as needed Click or tap here to enter Since 2yrs old Asthma exacerbations text. Advil 600mg Three times per day 2 Days per Menstrual cramps month 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. enter text. text. to enter text. 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.