Chronic Illnesses/Major traumas Hospitalizations/Surgeries
SOAP Note
Using this template, complete one SOAP note from a patient in your current NSG6440 clinical experience. The completed note should be submitted to the Submissions Area.
Submission Details:
Name your SOAP note document SU_NSG6440_W6_SOAPLastName_FirstInitial.doc.
Submit your document to the Submissions Area by the due date assigned.
This is a Pass/Fail assignment. A minimum of 15 points are needed, based on the assignment rubric, to pass.
Name:
Pt. Encounter Number:
Date:
Age:
Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats, and energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, and edema
Skin
Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB
Eyes
Corrective lenses, blurring, and visual changes of any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
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