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SOAP Note Format – MUSCULOSKELETAL

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CC Pain in lower back. “Tweaked” it while lifting a box. HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example: Onset: 3 days ago Location: Bilateral lower back. Does not radiate. Duration: 3 days Characteristics: Described as an ache, constant, does not radiate. Pain at its worst when she first injured her back stats 6-7/10. Current pain 5/10. Aggravatin...

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  • Case
  •  • 4 pages • 
  • by Derrigolised • 
  • uploaded  2021
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SOAP Note Format – HEENT

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Tina Jones Seen 1 month ago to establish care. S. CC “My throat has been sore…and itchy. And my nose won’t stop running. These symptoms are driving me nuts.” HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example: Onset: “2-7 days” Location: Throat, 4/10 Duration: Steady weight loss, 3-5 pounds per week Characteristics: “sore” throat…”jus...

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  • Case
  •  • 6 pages • 
  • by Derrigolised • 
  • uploaded  2021
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NUR 509SH Neuro>case SOAP Note Format – NEURO ASSESSMENT

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S - subjective CC: Ms. Jones reports getting into car accident 1 week ago. Has had headaches ever since the accident. Pt did not hit head during the accident. Friend’s car had little dent in back bumper, car that hit Ms. Jones and her friend had a slightly bigger dent in the front. Stated as “not serious” per patient. HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the ...

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  • Case
  •  • 4 pages • 
  • by Derrigolised • 
  • uploaded  2021
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HESI MED SURG EXAM. QUESTIONS AND ANSWERS.LATEST 2021. A+ RATED

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1) A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed.

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  • Exam (elaborations)
  •  • 60 pages • 
  • by Derrigolised • 
  • uploaded  2021
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