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NR 509 SOAP Note WEEK 7, NR 509 Advanced physical assessment. Chamberlain
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NR 509 SOAP Note WEEK 7, NR 509 Advanced physical assessment. Chamberlain
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SOAP Note TemplateS: Subjective
Information the patient or patient representative told you
Initials: Danny Age: 8 Gender: male
Height Weight BP HR RR Temp SPO2 Pain Allergies
Click Click or 120/ 100 28 37.2C 96% RA 2/10 Medication: none
or tap tap 76 Food: none
here to here to Environment: none
enter enter
text. text.
History of Present Illness (HPI)
Chief Complaint (CC) c/o cough, runny nose, right ear pain,sore throat CC is a BRIEF statement identifying
Onset Cough, runny nose-5 days ago, right ear pain and sore throat since yesterday why the patient is here - in the
Location Right ear, chest, throat, nose patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Reports constant cough and runny nose for 5 days day and night, keeps him
days”. Sometimes a patient has more
awakw at night. States sore throat/ right ear pain are constant since yesterday
than one complaint. For example: If
Characteristics Reports a clear wet, gurlgy persistent cough, worsening at night, but not with the patient presents with cough and
lying flat. Denies chills, fever, bodyaches or weakness,but states he is tired sore throat, identify which is the CC
since onset of cough, mild sore throat without difficulty swallowing, right ear and which may be an associated
pain and a persistent clear runny nose. Denies nausea, vomiting or diarrhea, symptom
shortness of breath or trouble with deep breathing. Denies decrease in
acitivties, or appetite.
Aggravating Factors Nothing makes it worse- denies knowing any triggers.
Relieving Factors Moms pruple cough medicine this morning
Treatment Purple cough medicine this am.
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
Purple Cough Syrup 1 dose once One time cough
OTC multivitamin 1 pill daily Unknown “ for health”
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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.
Allergies:
-Denies any food, medicine, environment, latex
PMHx:
-Pneumonia- last year ( no hospitalizations)
PSx:
-Denies
Immunizations:
-Not up to dat on flu shot
-Childhood immunization up to date per pediatric scheduling
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.
Tobacco: Denies use
Secondhand smoke: family smokes at home both in and out of home
School: Attends 3yr grade regularly ( only absent was last year for pneumonia)
Hobbies: making and watching movies, spending time with best friend Tony, video games, board games
Primary language: English, but is being taught Spanish by grandparents
Sexual Activity: Denies any activity
Household: lives with both working parents and maternal grandparents
Sports: denies participation
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.
Mother: DM, HTN, High cholesterol, spinal stenosis, obesity
Father: HTN, smoker, high cholesterol, asthma as child
Maternal Grandparents: DM, HTN, smoker, Eczema
Paternal Grandparents- grandfather-unknown, grandmother dies in MVC (52yr old)
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