Chamberlain College of Nursing - NR 509 Week 4 Soap Note

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NR 509 Week 4 Soap Note

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S: Subjective Information the patient or patient representative told you. Initials: BF Age: 58 years old Gender: Male Height: 5’11” Weight: 197lbs BP: 146/90 HR: 104 Temp: 19 SPO2: 98% Pain (1-10): 0/10 Allergies Medication: Codeine—Nausea and vomiting Food: No Known Food Allergies Environment: No Known Environmental Allergies History of Present Illness (HPI) CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance...

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