Chamberlain College of Nursing - NR 509 Week 4 Soap Note.
, NR 509 WEEK 4 SOAP
NOTES TEMPLATE
S: Subjective
Information the patient or patient representative told you.
Initials: BF
Age: 58 years old
Gender: Male
Height: 5’11”
Weight: 197lbs
BP: 146/90
HR: 104
Temp: 19
SPO2: 98%
Pain (1-10): 0/10
Allergies
Medication: Codeine—Nausea and vomiting
Food: No Known Food Allergies
Environment: No Known Environmental Allergies
History of Present Illness (HPI)
CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance
"headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For
example: If the patient presents with cough and sore throat, identify which is the CC and which may be
an associated symptom
Chief Complaint (CC): Chest Pain/Tightness
Onset: 1 month
Location: Center of my chest”
Duration: “It lasts 2-3 minutes when it happens”
Characteristics: “Intermittent tightness and discomfort”
Aggravating Factors: Activity, yard work, climbing stairs
Relieving Factors: Rest
Treatment: No medication treatments, seeking medical treatment today
Current Medications
Medication Dosage Frequency Length of Time Reason for Use
Used
Metoprolol 100mg Daily 1 year Hypertension
Atorvastatin 20mg Daily at 1 year High cholesterol
bedtime
Omega 3 Fish 1200mg Twice Daily 1 year High cholesterol
Oil
, NR 509 WEEK 4 SOAP
NOTES TEMPLATE
S: Subjective
Information the patient or patient representative told you.
Initials: BF
Age: 58 years old
Gender: Male
Height: 5’11”
Weight: 197lbs
BP: 146/90
HR: 104
Temp: 19
SPO2: 98%
Pain (1-10): 0/10
Allergies
Medication: Codeine—Nausea and vomiting
Food: No Known Food Allergies
Environment: No Known Environmental Allergies
History of Present Illness (HPI)
CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance
"headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For
example: If the patient presents with cough and sore throat, identify which is the CC and which may be
an associated symptom
Chief Complaint (CC): Chest Pain/Tightness
Onset: 1 month
Location: Center of my chest”
Duration: “It lasts 2-3 minutes when it happens”
Characteristics: “Intermittent tightness and discomfort”
Aggravating Factors: Activity, yard work, climbing stairs
Relieving Factors: Rest
Treatment: No medication treatments, seeking medical treatment today
Current Medications
Medication Dosage Frequency Length of Time Reason for Use
Used
Metoprolol 100mg Daily 1 year Hypertension
Atorvastatin 20mg Daily at 1 year High cholesterol
bedtime
Omega 3 Fish 1200mg Twice Daily 1 year High cholesterol
Oil
