Nr 509 Soap Note Week 1 2 Advanced Physical Assessment

!SOAP Note Template S: Subjective Information the patient or patient representative told youInitials: T.J.Age: 28Gender: FemaleHeightWeightBPHRRRTempSPO2PainAllergies 170 cm90 kg142/828619101.199%7/10Medication: Penicillin- rash/hives Food: no known food allergies Environment: Cat dander, dust- sneezes, pruritus, asthma flare-up History of Present Illness (HPI)Chief Complaint (CC)Infected wound to footCC 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 symptomOnsetWound occurred a week go with pain getting worse 2 days agoLocationPlantar aspect of right footDuration1 weekCharacteristicsRed, swollen, pus, warm to touchAggravating FactorsWalking and weight bearingRelieving FactorsPain medications and restingTreatmentCleans with soap and water twice a day, uses Neosporin twice a day, covers with a bandageCurrent Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Medication (Rx, OTC, or Homeopathic)DosageFrequencyLength of Time UsedReason for UseTramadol50 mgThree times a day (TID)2 daysPain MetforminunknownTwice a day (BID)3 years agoDiabetesAlbuterol Inhaler90 mcgPRN (2-3 times a week)3 days agoAsthma!Advil 600 mg PRN TIDunknownMenstrual Cycle CrampsClick or