JEFFERSON COLLEGE OF NURSING
NU 673 Comprehensive Assessment in Clinical Decision Making
SOAP Note Abd
Student Name: Date:03/28/2025
• Patient identification/verification: Jackie Smith 25 y/o female 03/28/1998
• Provider identification: NP in primary care office did not disclose name
• Patient Pronouns: She/Her
• Hand washing: Performed as provider walked in
1. (S) Subjective findings:
• Chief Complaint: “My stomach is killing me-Abdominal Pain”
• History of Present Illness: Pt is a 25-year-old female who is complaining of stomach
pain that started yesterday. She says that there have been no changes in her diet and that
she hasn’t had any alcohol for the past 2 weeks. She has not been seen anywhere else for
this problem. She says that the pain is located at the RLQ under her “bellybutton”. She
describes the pain as sharp and stabby with nausea. She says the severity of the pain is a
9/10. She has not taken any medication for the pain.
• Medications: None
OTC: Would have asked if she takes any over the counter medications
Herbals: Would have asked her if she takes any herbals
Supplements: None
• Allergies (medication/food/environment): NKA
I would have asked the patient if she had allergies to medications or to food or to the
environment.
• Past medical history (childhood, adult):
o Medical: No significant past medical History. Never been hospitalized.
, o Surgical history: Tonsillectomy at 8 y/o. No other procedures.
o OB/GYN history: Never been pregnant. I would have asked her if she has ever
had any gynecological problems. Has she ever had an ovarian cyst.
Psychiatric history: No significant psychiatric illness.
Family history:
Mother: No History given. I would have asked her about mothers’ medical history
Father: 57 y/o Hypertension- I would have asked the age of onset since the patient is also
hypertensive
Grandfather: 80 y/o Hypertension. Would have asked the age of onset. Would have asked
if this was Paternal or Maternal
I would have asked her about the history of her grandparents on both sides. I also would
have asked her if she has siblings and their medical history
• Social history: Pt is a nurse at Jefferson. She works nightshift in the NICU and reports
that it can be draining. She hopes to switch to day shift. (Would have asked her how
working nightshift interferes or is affecting her normal activities of daily living. Does she
get enough rest/sleep during the day? How many hours does she sleep). Reports eating a
well-balanced diet. Says she exercise 2-3 times per week, mostly cycling and swimming.
She drinks about 2-3 glasses of wine on the weekend with her friends. She denies any
past or current use of tobacco, cannabis, cocaine, heroin, or amphetamines. She is
sexually active and has vaginal and oral sex. She uses condoms for STI prevention and
birth control. She was in a monogamous relationship with her boyfriend until he cheated
on her, and she broke up with him. I would have asked if she has been sexually active
NU 673 Comprehensive Assessment in Clinical Decision Making
SOAP Note Abd
Student Name: Date:03/28/2025
• Patient identification/verification: Jackie Smith 25 y/o female 03/28/1998
• Provider identification: NP in primary care office did not disclose name
• Patient Pronouns: She/Her
• Hand washing: Performed as provider walked in
1. (S) Subjective findings:
• Chief Complaint: “My stomach is killing me-Abdominal Pain”
• History of Present Illness: Pt is a 25-year-old female who is complaining of stomach
pain that started yesterday. She says that there have been no changes in her diet and that
she hasn’t had any alcohol for the past 2 weeks. She has not been seen anywhere else for
this problem. She says that the pain is located at the RLQ under her “bellybutton”. She
describes the pain as sharp and stabby with nausea. She says the severity of the pain is a
9/10. She has not taken any medication for the pain.
• Medications: None
OTC: Would have asked if she takes any over the counter medications
Herbals: Would have asked her if she takes any herbals
Supplements: None
• Allergies (medication/food/environment): NKA
I would have asked the patient if she had allergies to medications or to food or to the
environment.
• Past medical history (childhood, adult):
o Medical: No significant past medical History. Never been hospitalized.
, o Surgical history: Tonsillectomy at 8 y/o. No other procedures.
o OB/GYN history: Never been pregnant. I would have asked her if she has ever
had any gynecological problems. Has she ever had an ovarian cyst.
Psychiatric history: No significant psychiatric illness.
Family history:
Mother: No History given. I would have asked her about mothers’ medical history
Father: 57 y/o Hypertension- I would have asked the age of onset since the patient is also
hypertensive
Grandfather: 80 y/o Hypertension. Would have asked the age of onset. Would have asked
if this was Paternal or Maternal
I would have asked her about the history of her grandparents on both sides. I also would
have asked her if she has siblings and their medical history
• Social history: Pt is a nurse at Jefferson. She works nightshift in the NICU and reports
that it can be draining. She hopes to switch to day shift. (Would have asked her how
working nightshift interferes or is affecting her normal activities of daily living. Does she
get enough rest/sleep during the day? How many hours does she sleep). Reports eating a
well-balanced diet. Says she exercise 2-3 times per week, mostly cycling and swimming.
She drinks about 2-3 glasses of wine on the weekend with her friends. She denies any
past or current use of tobacco, cannabis, cocaine, heroin, or amphetamines. She is
sexually active and has vaginal and oral sex. She uses condoms for STI prevention and
birth control. She was in a monogamous relationship with her boyfriend until he cheated
on her, and she broke up with him. I would have asked if she has been sexually active
