Derrigolised
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SOAP Note Format – MUSCULOSKELETAL
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...
- Case
- • 4 pages •
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...
SOAP Note Format – HEENT
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...
- Case
- • 6 pages •
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...
NUR 509SH Neuro>case SOAP Note Format – NEURO ASSESSMENT
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 ...
- Case
- • 4 pages •
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 ...
HESI MED SURG EXAM. QUESTIONS AND ANSWERS.LATEST 2021. A+ RATED
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.
- Exam (elaborations)
- • 60 pages •
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.