Ti na j ones re spi ra toryweek
2
TINA JONES
RESPIRATORY
WEEK 2
TINA JONES
RESPIRATORY
WEEK 2
, SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: TJ 5674 w 1st ave Spinghill Fl Age: 28 Gender: female
34606
Height Weight BP HR RR Temp SPO2 Pain Allergies
170 89 kg 140/ 89 20 98.5 97% Medication: Penicillin
cm 81 Food: Na
Environment: Cats
History of Present Illness (HPI)
Chief Complaint (CC) Chest tightness, shortness of breath, wheezing, hacky cough, fatigue CC is a BRIEF statement identifying
Onset 2 days ago why the patient is here - in the
Location Chest and lungs patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration 2 days days”. Sometimes a patient has more
Characteristics Tightness in chest with shortness of breath, dry hacky cough than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Allergies to cats sore throat, identify which is the CC
Relieving Factors Proventil inhaler with some relief and which may be an associated
Treatment Patient has been using an inhaler every 4 hours with very little relief symptom
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
(Rx, OTC, or Homeopathic)
Dosage Frequency Used Reason for Use
Proventil 90 mcg 2 puffs Q 4-6 hrs prn Since 2.5 years Asthma
old
Tylenol 500 mg 1-2 tabs Every 6 hrs undetermined Head aches and body pain
Ibuprofen 200 mg 1-2 tab Q6 hrs undetermined Cramps body aches
2
TINA JONES
RESPIRATORY
WEEK 2
TINA JONES
RESPIRATORY
WEEK 2
, SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: TJ 5674 w 1st ave Spinghill Fl Age: 28 Gender: female
34606
Height Weight BP HR RR Temp SPO2 Pain Allergies
170 89 kg 140/ 89 20 98.5 97% Medication: Penicillin
cm 81 Food: Na
Environment: Cats
History of Present Illness (HPI)
Chief Complaint (CC) Chest tightness, shortness of breath, wheezing, hacky cough, fatigue CC is a BRIEF statement identifying
Onset 2 days ago why the patient is here - in the
Location Chest and lungs patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration 2 days days”. Sometimes a patient has more
Characteristics Tightness in chest with shortness of breath, dry hacky cough than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Allergies to cats sore throat, identify which is the CC
Relieving Factors Proventil inhaler with some relief and which may be an associated
Treatment Patient has been using an inhaler every 4 hours with very little relief symptom
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
(Rx, OTC, or Homeopathic)
Dosage Frequency Used Reason for Use
Proventil 90 mcg 2 puffs Q 4-6 hrs prn Since 2.5 years Asthma
old
Tylenol 500 mg 1-2 tabs Every 6 hrs undetermined Head aches and body pain
Ibuprofen 200 mg 1-2 tab Q6 hrs undetermined Cramps body aches
