NR 509 Week 1 iHuman SOAP Note Template
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| Institution | NR 509 Advanced Physical Assessment |
| Contributor | Bradley |
SOAP Note Template
Initials: T. J | Age: 28 | Gender: Female | ||||||||||
Height | Weight | BP | HR | RR | Temp | SPO2 | Pain Rating | Allergies (and reaction) | ||||
170 cm | 90kg | 142/ 82 | 86 | 19 | 101.1 | 99% | 7/10 | Medication: Penicillin: Rash/ Hives Food: N/A Environment: Cat dander- sneezes, pruritus, asthma flare-up | ||||
History of Present Illness (HPI) | ||||||||||||
Chief Complaint (CC) | Infected wound to foot | 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 complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom | ||||||||||
Onset | Wound occurred a week go with pain getting worse 2 days ago | |||||||||||
Location | Planter aspect of right foot | |||||||||||
Duration | 1 week | |||||||||||
Characteristics | Red, swollen, purulent drainage, warm to touch | |||||||||||
Aggravating Factors | Walking and weight bearing | |||||||||||
Relieving Factors | Pain medications and resting | |||||||||||
Treatment | Cleans with soap and water twice a day, uses Neosporin twice a day, covers with a bandage | |||||||||||
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. | ||||||||||||
Medication (Rx, OTC, or Homeopathic) | Dosage | Frequency | Length of Time Used | Reason for Use | ||||||||
Tramadol | 50 mg | (TID) | 2 days | Pain | ||||||||
Metformin | unknown | BID | 3 years ago | Diabetes | ||||||||
Albuterol Inhaler | 90 mcg | PRN (2-3x a week) | 3 days ago | Asthma | ||||||||
Advil | 600 mg | PRN TID | unknown | Menstrual cycle cramps | ||||||||
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, | ||||||||||||
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| Instituition / Term | |
| Term | Year 2022 |
| Institution | NR 509 Advanced Physical Assessment |
| Contributor | Bradley |
