Jody Rush, 20 Y/O Female; SBAR,SOAP NOTE AND CAREPLAN
Jody Rush, 20 y/o female, admitted for right femur fracture status post skiing accident. She is in a
traction splint, and will be going for surgical repair today. Vital signs are BP 120/62 P 88 R 20 T 98.9 F,
37.2 C, PaO2 99. She has been in a lot of pain, and has been receiving 25 mcg IVP, q2 hours Fentanyl for
pain. She was nauseated after her last Fentanyl dose, and the Dr. Ordered an additional 4mg IVP, Zofran.
She has a history of exercise induced asthma, and uses a rescue inhaler, Albuterol. Her parents are on
their way; they are flying in today. She was on a ski trip with some of her friends from college; her best
friend has been camped out with her. We were able to get her on a bed pan earlier, but it took a lot of
work. We just received an order for a foley catheter. There was some concern that she may have
sustained a head injury as she has an abrasion to her forehead, but she denies ever losing
consciousness. Patients affected extremity has normal pulses, and the capillary refill is less than 3
seconds.
an SBAR , SOAP AND A CAREPLAN FOR PT BELOW
General: Jody rush 20 y/o female
1
, CC: admitted for right femur fracture status post skiing accident.
SOAP:
Subjective
2
Jody Rush, 20 y/o female, admitted for right femur fracture status post skiing accident. She is in a
traction splint, and will be going for surgical repair today. Vital signs are BP 120/62 P 88 R 20 T 98.9 F,
37.2 C, PaO2 99. She has been in a lot of pain, and has been receiving 25 mcg IVP, q2 hours Fentanyl for
pain. She was nauseated after her last Fentanyl dose, and the Dr. Ordered an additional 4mg IVP, Zofran.
She has a history of exercise induced asthma, and uses a rescue inhaler, Albuterol. Her parents are on
their way; they are flying in today. She was on a ski trip with some of her friends from college; her best
friend has been camped out with her. We were able to get her on a bed pan earlier, but it took a lot of
work. We just received an order for a foley catheter. There was some concern that she may have
sustained a head injury as she has an abrasion to her forehead, but she denies ever losing
consciousness. Patients affected extremity has normal pulses, and the capillary refill is less than 3
seconds.
an SBAR , SOAP AND A CAREPLAN FOR PT BELOW
General: Jody rush 20 y/o female
1
, CC: admitted for right femur fracture status post skiing accident.
SOAP:
Subjective
2
