NR 602 SOAP NOTE FORMAT

NR 602 SOAP NOTE FORMAT

, Week 6
NR 602 SOAP Note Format


- KaylaPatient Information: 26y/o Caucasian/Hispanic


female


S.


CC - fatigue, dysuria, and pain in her left breast


HPI: 26y/o Caucasian/Hispanic female with c/o fatigue, dysuria and L breast pain for a couple of
days. Endorses mild myalgia in L breast and describes pain as burning and superficial but no
nipple discharge. Does not identify aggravating or relieving factors or pharmacotherapy use.
C/O dysuria noted before breast pain but no monitoring for fever. Does not identify duration,
aggravating/relieving factors or pharmacotherapy use
Pt also c/o stress and fatigue, daughter recently hospitalized. Does not endorse
onset/duration/characteristics/aggravating factors/relieving factor/pharmacotherapy use.
Otherwise denies diarrhea, constipation, abdominal pain, skin changes, cough, or chest pain. No
recent physical or well woman exam since the birth of her son 2yrs ago.


Current Medications: None Listed


Allergies: None Listed


PMHx:
Gestational diabetes with last pregnancy (diagnosed 2 years ago)
PCOS – date diagnosed not listed.


PSHx:
Cesarean section x2


OB/Gyn Hx:
GTPAL: 21102