nr 509 week 7 soap note template chamberlin university
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NR 509 WEEK 7 SOAP Note Template
Chamberlin University
S: Subjective
Information the patient or patient representative told you
Initials: DR Age: 8 y/o Gender: M
Height Weight BP HR RR Temp SPO2 Pain Allergies
4’2” 90 lbs 120/ 100 28 37.2 c 96 Medication: None
76 98.9 f Food: Click or tap here to enter text.
Environment: Click or tap here to enter text.
History of Present Illness (HPI) Treatment OTC cough
Chief Complaint (CC) “I’ve been feeling sick, I’ve been coughing a lot, and I feel kind of tired”. syrup. “I
don't know
what the
Onset “The cough started five days ago”
name of
Location Chest
the cough
Duration ”I just keep feeling like I have to cough every couple minutes or so.” medicine is.
It was
Characteristics Cough is productive. Described as “gurgly and watery.” Sputum is clear. purple.”
CC is a BRIEF statement identifying why
Aggravating Factors “My cough mostly stays the same no matter what I do. It seems to get worse the patient is here - in the patient’s own
at night though.” words - for instance "headache", NOT
Relieving Factors OTC cough syrup provided some temporary relief of cough. “It helped a bit "bad headache for 3 days”. Sometimes a
when my mom gave it to me, but my cough came back anyway.” 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 symptom
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Dosage Frequency Length of Time Reason for Use
, (Rx, OTC, or Homeopathic) Used
Multivitamin Gummy Unknown Daily Unknown “to be healthy”
Purple Cough medicine (OTC) Small teaspoon This morning Unknown Cough
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enter text. text. to enter text.
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enter text. text. to enter text.
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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.
No influenza vaccine in previous 12 months
Hep A series completed at 15 months
Heb B series completed at 6 months
Pneumococcal series completed at 15 months
DTap series completed at 6 yrs
MMR series completed at 6 yrs
Varicella series complete at 6 yrs
Polio series completed at 6 yrs
No surgical hx
No prior hospitalizations
Pneumonia last year (seen/treated in urgent care)
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.
3rd grade student – missed 2 weeks of school d/t pneumonia
Lives with both parents and grandmother
English primary language; Spanish secondary
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