NR 509 Week 3 iHuman SOAP Note Template
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$20.00
| Institution | NR 509 Advanced Physical Assessment |
| Contributor | Bradley |
SOAP Note Template
| S: Subjective Information the patient or patient representative told you | |||||||||||||||
| Initials: A.W. | Age: 23 | Gender: Female |
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Height | Weight | BP | HR | RR | Temp | SPO2 | Pain Rating | Allergies (and reaction) |
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5’7 | 120 | 126/ 80 | 94 | 14 | 101.5 | 98 |
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| Medication: Click or tap here to enter text. Food: Click or tap here to enter text. Environment: Click or tap here to enter text. |
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History of Present Illness (HPI) |
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Chief Complaint (CC) | Sore throat and headache | 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 |
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Onset | 2 days ago | |||||||||||||||
Location | Throat and head | |||||||||||||||
Duration | Constant | |||||||||||||||
Characteristics | Feels like an ice pick is in her throat | |||||||||||||||
Aggravating Factors | None | |||||||||||||||
Relieving Factors | Tylenol | |||||||||||||||
Treatment | Antibiotics | |||||||||||||||
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. |
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Medication (Rx, OTC, or Homeopathic) | Dosage | Frequency | Length of Time Used | Reason for Use |
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| Instituition / Term | |
| Term | Year 2022 |
| Institution | NR 509 Advanced Physical Assessment |
| Contributor | Bradley |
