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NR 509 SOAP Note WEEK 6, S: Subjective NR 509 Advanced physical assessment
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NR 509 SOAP Note WEEK 6 S: Subjective NR 509 Advanced physical assessment
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SOAP NOTES TEMPLATENR 509 SOAP Note WEEK 6
S: Subjective
NR 509 Advanced physical assessment
, SOAP NOTES TEMPLATE
S: Subjective
Information the patient or patient representative told you.
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 allergies
History of Present Illness (HPI)
Chief Complaint (CC): Cough
Onset: 5 days ago
Location: Chest
Duration: Frequent (every couple of minutes without trigger noted)
Characteristics: Wet, productive with clear sputum
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