NR509 Week 2 / NR 509 Chapter 2 SOAP Note – Chamberlain College of Nursing

NR509 Week 2 SOAP Note – Chamberlain College of Nursing 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 Relieving Factors: Proventil inhaler, less effective than usual Treatment: Proventil inhaler