NR509 WEEK 4 SOAPNOTE
SOAP Note Template
Initials: BF Age: 58 Gender: Male
Height Weight BP HR RR Temp SPO2 Pain Allergies
5’ 11 197lbs 146/
90
104 19 36.7C 98% Medication: Codeine : reports causes nausea and vomi
...
NR509 WEEK 4 SOAPNOTE
SOAP Note Template
Initials: BF Age: 58 Gender: Male
Height Weight BP HR RR Temp SPO2 Pain Allergies
5’ 11 197lbs 146/
90
104 19 36.7C 98% Medication: Codeine : reports causes nausea and vomiting
Food: none
Environment: none
History of Present Illness (HPI)
Chief Complaint (CC) Chest pain 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 While doing strenuous acitivties, earlier this month.
Location Middle of chest. Does not radiate.
Duration 3 episodes for the past month. Each episode lasts for a couple of minutes.
Characteristics Chest tightness in the middle of chest without radiation.
Aggravating Factors Yard work and climbing stairs at work.
Relieving Factors Taking a break or sat down to rest.
Treatment Reports no treatment uses
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
Atorvastatin (Lipitor) PO 10mg Daily at HS One year High Cholesterol
Metoprolol (Lopressor) PO 100mg Daily One year High blood pressure
Omega-3 Fish Oil PO 1200mg Daily Unable to
respond ( last
dose taken this
AM)
Does not respond when asked why.
Tylenol “Whatever the bottle
recommends for an
adult”
PRN PRN For Headache
Ibuprofen “Whatever the bottle
recommends for an
adult”
PRN PRN Varioius aches and pains
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