NURSING EXAM TEST
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
,nursing exam test
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: T.J. Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170 88 kg 139/ 82 16 98.9 F 99% Medication: Penicillin-Rash/Hives
cm 87 Food: No known food allergies
Environment: Cats & Dust-Sneezing, itchy eyes, asthma flare ups.
History of Present Illness (HPI)
Chief Complaint (CC) “Well I got into a fender bender a week ago and I’ve been getting these CC is a BRIEF statement identifying
headaches ever since and my neck is sore too” why the patient is here - in the
patient’s own words - for instance
Onset 5 days ago ( days post accident)
"headache", NOT "bad headache for 3
Location Head and neck days”. Sometimes a patient has more
than one complaint. For example: If
Duration Headache occurs once a day, last 1-2 hours
the patient presents with cough and
Characteristics Dull ache in the crown and back of the head bilaterally, pain in the bilateral sore throat, identify which is the CC
temples and behind the eyes. and which may be an associated
symptom
Aggravating Factors Denies any aggravating factors for headache, but states neck soreness is
exacerbated and painful with movement of the head/neck.
Relieving Factors Tylenol and rest
Treatment Currently takes Tylenol 2 regular strength one a day for headache and neck
pain since accident.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
, nursing exam test
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Tylenol (Acetaminophen) Two 325mg tablets Once a day 7 days Daily headaches, and neck pain
Regular Strength
Proventil Inhaler (Albuterol) 90 mcg (1-2) puffs PRN as needed. (last used Since diagnosis Asthma Exacerbation
8 months ago)
of asthma at
age 2.5
Advil (Ibuprofen) Three 200mg tablets PRN up to three times a Unknown, takes Takes during menstrual cycle for
day during cramps
menstrual cycle
Flovent 44 mcg (2 puffs) Daily BID New Asthma
prescription
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
,nursing exam test
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: T.J. Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170 88 kg 139/ 82 16 98.9 F 99% Medication: Penicillin-Rash/Hives
cm 87 Food: No known food allergies
Environment: Cats & Dust-Sneezing, itchy eyes, asthma flare ups.
History of Present Illness (HPI)
Chief Complaint (CC) “Well I got into a fender bender a week ago and I’ve been getting these CC is a BRIEF statement identifying
headaches ever since and my neck is sore too” why the patient is here - in the
patient’s own words - for instance
Onset 5 days ago ( days post accident)
"headache", NOT "bad headache for 3
Location Head and neck days”. Sometimes a patient has more
than one complaint. For example: If
Duration Headache occurs once a day, last 1-2 hours
the patient presents with cough and
Characteristics Dull ache in the crown and back of the head bilaterally, pain in the bilateral sore throat, identify which is the CC
temples and behind the eyes. and which may be an associated
symptom
Aggravating Factors Denies any aggravating factors for headache, but states neck soreness is
exacerbated and painful with movement of the head/neck.
Relieving Factors Tylenol and rest
Treatment Currently takes Tylenol 2 regular strength one a day for headache and neck
pain since accident.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
, nursing exam test
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Tylenol (Acetaminophen) Two 325mg tablets Once a day 7 days Daily headaches, and neck pain
Regular Strength
Proventil Inhaler (Albuterol) 90 mcg (1-2) puffs PRN as needed. (last used Since diagnosis Asthma Exacerbation
8 months ago)
of asthma at
age 2.5
Advil (Ibuprofen) Three 200mg tablets PRN up to three times a Unknown, takes Takes during menstrual cycle for
day during cramps
menstrual cycle
Flovent 44 mcg (2 puffs) Daily BID New Asthma
prescription
