Running head: COMPREHENSIVE SOAP NOTE 1
SOAP Note Comprehensive SOAP Note
Walden University
Advanced Practice Care of Frail Elders NURS-6540F
Comprehensive SOAP Note
Patient Initials: _W.L._ Age: __72__ Gender: ___M
...
Running head: COMPREHENSIVE SOAP NOTE 1
SOAP Note Comprehensive SOAP Note
Walden University
Advanced Practice Care of Frail Elders NURS-6540F
Comprehensive SOAP Note
Patient Initials: _W.L._ Age: __72__ Gender: ___M__
COMPREHENSIVE SOAP NOTE 2
Subjective Data
Chief Complaint (CC): “I’m cold”
History of Present Illness (HPI): 72-year-old Caucasian male admitted to this facility under a
Baker Act for suicidal ideation and inability to care for himself. He lives with his wife who says
that he has not been eating well for about a week.
Medications: Home medications include: Carafate 1 gram PO QID, Zoloft 50 mg PO daily,
Lipitor 80 mg PO QHS, Protonix 40 mg PO daily, multivitamin 1 tab PO daily, Flomax 0.4 mg
PO daily, Plavix 75 mg PO daily, Aspirin 81 mg PO daily, Atenolol 50 mg PO daily, and folic
acid 1 mg PO daily.
The Beer’s criteria tool was developed to improve medication safety among the elderly.
After reviewing this patient’s current medications and comparing them with the Beers Criteria, I
have discovered that the medications this patient is taking are appropriate for his age.
(American Geriatrics Society, 2015).
Allergies: NKDA
Past Medical History (PMH): HTN, BPH, High cholesterol, COPD, Stroke, Dysphagia, ETOH
dependence
Past Surgical History (PSH): Patient denies
Personal/Social History: Patient reports he quit smoking 1-2 years ago. He drinks 6 beers daily
Immunization History: Unknown
Significant Family History: unknown
Review of Systems:
General: Patient lying in bed under the covers. He appears disheveled, thin, and dirty. He
reports chills and some weight loss but denies fever.
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