Nr 509 Advanced Physical Assessment Soap Note Pediatric Week 6

This study source was downloaded by 100000802832151 from CourseHero.com on 11-09-2022 04:01:07 GMT -06:00https://www.coursehero.com/file/62319172/NR509-SOAP-Note-Pediatric-week-6docx/ SOAP Note TemplateInitials : DR Age: 8 Gender: maleHeight Weight BP HR RR Temp SPO2 Pain Allergies 127cm 40.8kg 120/76 100 28 37.2C 96% Medication: noneFood: noneEnvironment: none History of Present Illness (HPI)Chief Complaint (CC) cough runny nose right ear pain tired sore throat CC is a BRIEF statement identifying why the patient is here - in the patients own words - for instance "headache", NOT "bad headache for 3days. 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 symptomO nset 5 days agoL ocation Throat, right earD uration Coughing:Constant with episodes every few minutes; Ear/Throat: constant: 1 dayC haracteristics Cough: gurgly, watery, constant; Throat: sore, painful to swallow; Ear: constant painA ggravating Factors Laying down at nightR elieving Factors Cough medicineT reatment Cough medicineCurrent 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 TimeUsed Reason for UseChildrens Multivitamin Gummies One gummy Once PO daily Click or tap