NR 509 Week 4 iHuman SOAP Note Template
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$20.00
| Institution | NR 509 Advanced Physical Assessment |
| Contributor | Bradley |
S: Subjective Information the patient or patient representative told you | |||||||||||||||
Initials: H.H | Age: 57 | Gender: Male | |||||||||||||
Height | Weight | BP | HR | RR | Temp | SPO2 | Pain Rating | Allergies: None | |||||||
5’9 | 195 | 172/ 94 | 76 | 14 | 98.6 | 96 |
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| Medication: Omeprazole Daily, Ibuprofen TID 800mg PRN Food: Fast food, TexMex, Chips Environment: Home with wife, construction worker | |||||
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History of Present Illness (HPI) | |||||||||||||||
Chief Complaint (CC) | High blood pressure, 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 | |||||||||||||
Onset | A few years ago | ||||||||||||||
Location | Head | ||||||||||||||
Duration | Intermittent | ||||||||||||||
Characteristics | Dull, in the morning. | ||||||||||||||
Aggravating Factors | None | ||||||||||||||
Relieving Factors | Ibuprofen | ||||||||||||||
Treatment | None | ||||||||||||||
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 | |||||||||||
Omeprazole | Click or tap here to enter text. | Daily | Click or tap here to enter text. | Gastritis | |||||||||||
Ibuprofen | 800mg | TID PRN | Years | Headache | |||||||||||
Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | |||||||||||
Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | |||||||||||
Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | |||||||||||
| Instituition / Term | |
| Term | Year 2022 |
| Institution | NR 509 Advanced Physical Assessment |
| Contributor | Bradley |
