Nr 509 Soap Note Template 1 Abdomen 3 4 1

This study source was downloaded by 100000802832151 from CourseHero.com on 11-09-2022 04:32:02 GMT -06:00https://www.coursehero.com/file/64744942/NR509-SOAP-Note-Template-1Abdomen-3-4-1docx/ SOAP Note TemplateInitials : Esther Parks- 2343 E 29th Tampa,Fl 33434 Age: 78 Gender: FemaleHeight Weight BP HR RR Temp SPO2 Pain Allergies 56 123 110/70 92 16 16 99 Medication: NoneFood: NoneEnvironment: None, Latex - Contact Dermatitis History of Present Illness (HPI)Chief Complaint (CC) I have abdominal pain and difficulty going to bathroom. 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 Lower abdomenD uration Gradual increased pain over the past 2-3 daysC haracteristics Crampy and dullA ggravating Factors Activity and eatingR elieving Factors RestingT reatment No treatmentCurrent 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 UseAccupril 10 mg by mouth One time a day indefinately High blood pressureClick or tap