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*NURSING > Class Notes > NR509_SOAP_Note_Template.Abdomen (All)

NR509_SOAP_Note_Template.Abdomen

Document Content and Description Below

Initials: Esther Parks- 2343 E 29th Tampa,Fl 33434 Age: 78 Gender: Female Weight BP HR RR Temp SPO2 Pain Allergies 123 110/ 70 92 16 16 99 Medication: None Food: None Environment: None, Latex- Contact Dermatitis History of Present Illness (HPI) Chief Complaint (CC) “I have abdominal pain and difficulty going to bathroom.” 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 5 days ago Location Lower abdomen Duration Gradual increased pain over the past 2-3 days Characteristics Crampy and dull Aggravating Factors Activity and eating Relieving Factors Resting Treatment No treatment Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Accupril 10 mg by mouth One time a day indefinately High blood pressure Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.

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