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NR509 week 5 SOAP Note
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  • Course
  • NR509 (NR509)
  • Institution
  • Chamberlain College Of Nursing

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 p...

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  • June 1, 2022
  • 9
  • 2020/2021
  • Case
  • Prof
  • A+

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  • nr509
  • nr 509
  • nr509 week 5 soapnote

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  • Chamberlain College Of Nursing
  • NR509 (NR509)
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SOAP Note Template
S: Subjective
Information the patient or patient representative told you

Initials: E.P. Age: 78 Gender: Female

Height Weight BP HR RR Temp SPO2 Pain Allergies
5’ 2 120lbs 110/ 92 16 37.0C 99% Medication: NKDA
70 Food: Denies
Environment: Latex (itchy skin rash) dx at age 54
History of Present Illness (HPI)
Chief Complaint (CC) “Belly pain” CC is a BRIEF statement identifying
Onset 5 days ago why the patient is here - in the
Location Lower abdomen patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Constant. Worse when moving or when eating. ( worse 2-3 days)
days”. Sometimes a patient has more
Characteristics Constant. Dull and crampy. Generalized pain that stays in one place. (Last BM than one complaint. For example: If
5 days ago, non- radiating worsedn over 2-3 days) (Add associated char the patient presents with cough and
diarrhea, last BM) sore throat, identify which is the CC
Aggravating Factors Moving or after eating (put how it helped: little help ) and which may be an associated
Relieving Factors Resting and not moving ( put the degree of improvement what the pain is at symptom
after intervention)
Treatment None (sips of water no help, Anything they did even if tx did not work)
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Accupril (research med side 10mg Daily 24 yrs Hypertension
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, Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.


Last Bowel movement 5 days ago. No gastrointestinal history. Menopausal. Reports 3 pregnancies but
Last colonoscopy: 10yrs ago reports, results were negative. 2 colonoscopy’s total.
Surgical history includes: Cholecystectomy at age 42 and one C-section at 40 with her last pregnancy. Denies other hospitalizations.
No recent travel outside of USA in last few years. Hx: Stomach virus a few years ago for 24hrs. Last flu vaccine 2 years ago. Refuses flu vaccine at
this visit. Unable to recall date of last tetanus but states is currently up to date at this time.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.

( add if pt is happy? , add sexual history with BF, ) Born SF, grew up in Korean towen. Widow married 50 yrs. Jennifer lawyer, tim son director.
Retired nurse working at a rehabilitation clinic. Hobbies include gardening, walking a lot. Water aerobics 2-3 times a week. Started Pilates recently
for exercise. Lives with daughter Jennifer with good relationship, daughter is driver. Widow but has a significant other. Denies history or present
tobacco use. Reports first alcoholic drink on 13th birthday. Drinks one glass of white wine every Sunday filled in a normal glass of wine. Avoids
caffeinated drinks but ocassinally has chamomille tea.
-Reports only drinking 2 glasses of water daily, reports typical meal is toast or banana or peach for breakfast, skips lunch, and dinner is a protein
with rice. Reports vegetable intake every other day. Reports usually has a bowel movement every day or every other day. Reports diarrhea episode
prior to being constipated for the last 5 days. ( ask depression, 24hr diet recall, enjoys food in her culture.)

Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.

Father:Deceased at age 82, obesity, hx Heartburn, HTN, hypercholesterolemia
Mother:Deceased at 88, hx of HTN and DM 2.
Maternal grandparents: CAD, DM2, HTN
Paternal grandparents: hx obesity, CVA , HTN
Husband:passed away at 82 yrs old from a fall, resulting in brain hemorrhage
Brother(Christopher)81yr old – prostate cancer, HTN, hypercholesterolemia.
Brother (Michael) 80 -HTN
Daughter ( Jennifer)-age 46- healthy
Son 48- healthy (Add if history of colon cancer? Denies family colon ca history.)



Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.

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