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NR509 SOAP Notes for WEEK 1, 2, 3, 4, 5, 6 & 7
NR509 SOAP Notes for WEEK 1, 2, 3, 4, 5, 6 & 7
[Meer zien]NR509 SOAP Notes for WEEK 1, 2, 3, 4, 5, 6 & 7
[Meer zien]Initials: DR: 
 Age: 8 years old 
 Gender: Male 
 Height: 4’2” 
 Weight: 90lbs 
 BP: 120/91 
 HR: 100 
 RR: 28 
 FVC: 3.91 
 FEV1: 3.15 
 FEV1/FVC: 80.5% 
Temp: 37.2C 
 SPO2: 96% 
 Pain (1-10): 3 
Allergies 
Medication: NKDA 
Food: No known food allergies 
Environment: No known environmental all...
Voorbeeld 2 van de 13 pagina's
In winkelwagenInitials: DR: 
 Age: 8 years old 
 Gender: Male 
 Height: 4’2” 
 Weight: 90lbs 
 BP: 120/91 
 HR: 100 
 RR: 28 
 FVC: 3.91 
 FEV1: 3.15 
 FEV1/FVC: 80.5% 
Temp: 37.2C 
 SPO2: 96% 
 Pain (1-10): 3 
Allergies 
Medication: NKDA 
Food: No known food allergies 
Environment: No known environmental all...
S: Subjective 
Information the patient or patient representative told you. 
 Initials: BF 
 Age: 58 years old 
 Gender: Male 
 Height: 5’11” 
 Weight: 197lbs 
 BP: 146/90 
 HR: 104 
 Temp: 19 
 SPO2: 98% 
 Pain (1-10): 0/10 
Allergies 
Medication: Codeine—Nausea and vomiting 
Food: No Known Fo...
Voorbeeld 2 van de 14 pagina's
In winkelwagenS: Subjective 
Information the patient or patient representative told you. 
 Initials: BF 
 Age: 58 years old 
 Gender: Male 
 Height: 5’11” 
 Weight: 197lbs 
 BP: 146/90 
 HR: 104 
 Temp: 19 
 SPO2: 98% 
 Pain (1-10): 0/10 
Allergies 
Medication: Codeine—Nausea and vomiting 
Food: No Known Fo...
History of Present Illness (HPI) 
Chief Complaint (CC) “Breathing problems” 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:...
Voorbeeld 2 van de 8 pagina's
In winkelwagenHistory of Present Illness (HPI) 
Chief Complaint (CC) “Breathing problems” 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:...
S: Subjective 
Information the patient or patient representative told you. 
 Initials: JT 
 Age: 28 years 
 Gender: Female 
 Height: 170cm 
 Weight: 90kg 
 BP: 142/82 
 HR: 86 
 Temp: 101.1 
 SPO2: 99% 
 Pain (1-10): 7 
Allergies 
Medication: Penicillin 
Food: No known allergy 
Environment: Cats 
Hi...
Voorbeeld 2 van de 11 pagina's
In winkelwagenS: Subjective 
Information the patient or patient representative told you. 
 Initials: JT 
 Age: 28 years 
 Gender: Female 
 Height: 170cm 
 Weight: 90kg 
 BP: 142/82 
 HR: 86 
 Temp: 101.1 
 SPO2: 99% 
 Pain (1-10): 7 
Allergies 
Medication: Penicillin 
Food: No known allergy 
Environment: Cats 
Hi...
History of Present Illness (HPI) 
Chief Complaint (CC) “Belly pain” 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...
Voorbeeld 2 van de 9 pagina's
In winkelwagenHistory of Present Illness (HPI) 
Chief Complaint (CC) “Belly pain” 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...
SOAP NOTES TEMPLATE 
S: Subjective 
Information the patient or patient representative told you. 
 Initials: JT 
 Age: 28 years 
 Gender: Female 
 Height: 170cm 
 Weight: 88kg BMI: 30.5 
 BP: 139/87 
 HR: 82 RR: 16 
 Temp: 98.9 
 SPO2: 99% 
 Pain (1-10): 3/10 
Allergies 
Medication: Penicillin—Rash...
Voorbeeld 2 van de 10 pagina's
In winkelwagenSOAP NOTES TEMPLATE 
S: Subjective 
Information the patient or patient representative told you. 
 Initials: JT 
 Age: 28 years 
 Gender: Female 
 Height: 170cm 
 Weight: 88kg BMI: 30.5 
 BP: 139/87 
 HR: 82 RR: 16 
 Temp: 98.9 
 SPO2: 99% 
 Pain (1-10): 3/10 
Allergies 
Medication: Penicillin—Rash...
History of Present Illness (HPI) 
Chief Complaint (CC) c/o cough, runny nose, right ear pain,sore throat 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 on...
Voorbeeld 2 van de 8 pagina's
In winkelwagenHistory of Present Illness (HPI) 
Chief Complaint (CC) c/o cough, runny nose, right ear pain,sore throat 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 on...
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