NR 509 SOAP Note WEEK 5, S: Subjective NR 509 Advanced physical assessment

SOAP NOTES TEMPLATE




NR 509 SOAP Note WEEK 5
S: Subjective
NR 509 Advanced physical assessment

, SOAP NOTES TEMPLATE


S: Subjective
Information the patient or patient representative told you.


Initials: EP

Age: 78

Gender: Female

Height: 5’2”

Weight: 120 lbs

BP: 110/70

HR:92

Temp: 37.0 C

SPO2: 99

RR: 16

Pain (1-10): 6

Allergies:

Medication: NKDA

Food: none

Environment: Latex—“itchy rash”

History of Present Illness (HPI)

Chief Complaint (CC): “pain in my belly” and difficulty going to the bathroom

Onset: Constipation 5 days ago with the exception of an episode of was watery diarrhea 3 days ago

Location: “low in abdomen”

Duration: constant x 5 days

Characteristics: dull “crampy” feeling

Aggravating Factors: eating causes bloating and increased pain, physical activity

Relieving Factors: resting helps a little

Treatment: sips of warm water which did not work