NR 509 Abdominal Pain SOAP NOTE
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: E.P. Age: 78 Gender: F
Height Weight BP HR RR Temp SPO2 Pain Allergies
157.48 54 kg 110/ 92 16 37.0 C 99% 6/10 Medication: Latex (Rxn - itchy skin rash)
70
(5’2”) (120 Food: NKA
lbs)
Environment: NKA
History of Present Illness (HPI)
Chief Complaint (CC) “Belly pain” CC is a BRIEF statement identifying
why the patient is here - in the
Onset She is unsure what caused it, but she started having a difficult time going to the
patient’s own words - for instance
bathroom
"headache", NOT "bad headache for 3
Location Whole belly but mostly the lower part days”. Sometimes a patient has more
than one complaint. For example: If
Duration Consistent for the past 5 days. Pain worse 2-3 days ago the patient presents with cough and
Characteristics Dull and crampy sore throat, identify which is the CC
and which may be an associated
Aggravating Factors Movement and eating symptom
Relieving Factors Rest
Treatment Rest
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Accupril 10 mg Daily 24 years Hypertension
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Hypertension – diagnosed at age 54
Gallstones - age 42
C-section – two in her early 40s
Cholecystectomy
Colonoscopy – two; most recent was 10 years ago – nothing to report
Immunizations – up to date
Bowel movement – usually every day
Has not travelled in several years
Nutrition - typically eat three meals but sometimes skips breakfast and skips lunch if not feeling hungry
Breakfast: piece of toast
Lunch: soup
Dinner: rice with fish or chicken
Fiber source – at least one vegetable every 1-2 days and a fruit every 3-4 days
Fluid intake – two glasses a day; last few days, it has been difficult to drink much; chamomile tea
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: E.P. Age: 78 Gender: F
Height Weight BP HR RR Temp SPO2 Pain Allergies
157.48 54 kg 110/ 92 16 37.0 C 99% 6/10 Medication: Latex (Rxn - itchy skin rash)
70
(5’2”) (120 Food: NKA
lbs)
Environment: NKA
History of Present Illness (HPI)
Chief Complaint (CC) “Belly pain” CC is a BRIEF statement identifying
why the patient is here - in the
Onset She is unsure what caused it, but she started having a difficult time going to the
patient’s own words - for instance
bathroom
"headache", NOT "bad headache for 3
Location Whole belly but mostly the lower part days”. Sometimes a patient has more
than one complaint. For example: If
Duration Consistent for the past 5 days. Pain worse 2-3 days ago the patient presents with cough and
Characteristics Dull and crampy sore throat, identify which is the CC
and which may be an associated
Aggravating Factors Movement and eating symptom
Relieving Factors Rest
Treatment Rest
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Accupril 10 mg Daily 24 years Hypertension
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Hypertension – diagnosed at age 54
Gallstones - age 42
C-section – two in her early 40s
Cholecystectomy
Colonoscopy – two; most recent was 10 years ago – nothing to report
Immunizations – up to date
Bowel movement – usually every day
Has not travelled in several years
Nutrition - typically eat three meals but sometimes skips breakfast and skips lunch if not feeling hungry
Breakfast: piece of toast
Lunch: soup
Dinner: rice with fish or chicken
Fiber source – at least one vegetable every 1-2 days and a fruit every 3-4 days
Fluid intake – two glasses a day; last few days, it has been difficult to drink much; chamomile tea
