NR 509 SOAP Note WEEK 2, S: Subjective NR 509 Advanced physical assessment

SOAP NOTES TEMPLATE




NR 509 SOAP Note WEEK 2
S: Subjective
NR 509 Advanced physical assessment

, SOAP NOTES TEMPLATE




S: Subjective
Information the patient or patient representative told you.
Initials: JT
Age: 28 years
Gender: Female
Height: 170cm
Weight: 89kg
BP: 140/81
HR: 89
Temp: 98.5
SPO2: 97%
Pain (1-10): 0


Allergies

Medication: Penicillin
Food: No known allergy
Environment: Cats


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): Recent asthma attack which is not fully resolved
Onset: 2 days ago, while visiting cousin with cats
Location: N/A
Duration: 2 days
Characteristics: Chest tightness, worse when laying down & at night. Persistent cough x2 days
Aggravating Factors: Physical activity, laying down