CARDIO SOAP NOTE

SOAP Note Template Initials: BF Age: 58 Gender: M Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction) 5’11” 197lbs left arm: 146/ 88 Righ t arm: 146/ 90 104 19 36.7 98% 0/10 Medication: Codeine (N/V) Food: none Environment:none History of Present Illness (HPI) Chief Complaint (CC) chest pain 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 Onset one month ago Location Middle of his chest Duration Pain is felt 5 out of 10 and last for a few minutes then goes away with rest Characteristics tightness, uncomfortable in the middle of chest, does not radiate Aggravating Factors something physical such as yard work pulling weeds, or going up the stairs Relieving Factors lying down, rest Treatment none Current Medications: Include dosage, frequency, length of time used and reason for use; also include OT