NR 509 SOAP Note WEEK 6, S: Subjective NR 509 Advanced physical assessment

SOAP NOTES TEMPLATE




NR 509 SOAP Note WEEK 6
S: Subjective
NR 509 Advanced physical assessment

, SOAP NOTES TEMPLATE




S: Subjective
Information the patient or patient representative told you.
Initials: DR:
Age: 8 years old
Gender: Male
Height: 4’2”
Weight: 90lbs
BP: 120/91
HR: 100
RR: 28
FVC: 3.91
FEV1: 3.15
FEV1/FVC: 80.5%
Temp: 37.2C
SPO2: 96%
Pain (1-10): 3


Allergies

Medication: NKDA
Food: No known food allergies
Environment: No known environmental allergies


History of Present Illness (HPI)

Chief Complaint (CC): Cough

Onset: 5 days ago

Location: Chest

Duration: Frequent (every couple of minutes without trigger noted)

Characteristics: Wet, productive with clear sputum