NURS 6512 Week 9 Shadow Health Comprehensive SOAP Note Template

Week 9 Shadow Health Comprehensive SOAP Note Template Patient Initials: TJ Age: 28 Gender: Female SUBJECTIVE DATA: Chief Complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of Present Illness (HPI): Presents for a general physical examination in preparation for her new position as an accounting clerk at Smith, Stevens, Silver & Company. She denies having any serious issues. She visited a gynecologist for a checkup four months prior, during which a PCOS diagnosis was made, and a daily birth control regimen was prescribed. She states that (Drospirenone/ethinyl estradiol) is taken consistently every day with satisfactory symptom management. She had a physical examination five months prior, during which she was prescribed Metformin for her diabetes and a daily inhaler every day for her asthma. Her vision is now clearer, and she no longer experiences migraines after seeing an eye doctor three months ago. She claims that metformin, a healthy diet, and exercise are helping her manage her diabetes. She routinely monitors her blood sugar levels each day. The last time a rescue inhaler was used was three months ago with usage reducing to twice yearly. The patient keeps a journal and measures her peak flow at home.