nr 509 week 7 soap note template chamberlin university
Written for
Nursing
nursing
Nursing
All documents for this subject (41214)
Seller
Follow
henryexaminer
Content preview
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
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
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
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller henryexaminer. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $22.63. You're not tied to anything after your purchase.
