Nr 509 Soap Note Ester Park Week 5 -Complete Soap Note Ester Park Including Ros/hpi

SOAP Note TemplateInitials: EPAge: 78Gender: FemaleHeight Weight BP HR RR Temp SPO2 Pain RatingAllergies (and reaction)52 120 110/ 7092 16 37.0 99 Medication: NKDAFood: NONE Environment: Late (itchy rash) History of Present Illness (HPI) Chief Complaint (CC) Abdominal pain and difficulty going to the bathroom CC is a BRIEF statement identifying why the patient is here - in the patients 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 symptomOnset 5 days agoL ocation Low in abdomenD uration Constant for 5 daysC haracteristics Dull and crampyA ggravating Factors Eating and physical activityR elieving Factors RestingT reatment Sips of warm water with no reliefCurrent Medications: Include dosage, frequency, length of time used and reaso n for use; also include OTC or homeopathic products.Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of TimeUsed Reason for UseAccupril 10mg daily Unknown HypertensionClick or tap here to enter text. Click or tap here to enter text.Click or tap here to enter text. Click or tap hereto enter text. Click or tap here