SOAP Note Template - HeightWeightBP HR RRTemp SPO2 Pain Rating Aller...

SOAP Note Template Initials: tjAge: 28Gender: female HeightWeightBP HR RRTemp SPO2 Pain Rating Allergies (and reaction) 170 88 Click or tap here to ente r text.Clic k or tap here to ente r text.Clic k or tap her e to ent er text.Click or tap here to enter text.Click or tap here to enter text.

Medication: penicillin-hives

Food: none

Environment: : Cat dander- sneezes, asthma flare-up, pruritus History of Present Illness (HPI) Chief Complaint (CC)Patient present to the clinic after having a “fender bender” approx 1 week ago, now the patient is having headaches and neck 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 Onset5 days LocationPain is located at the crown and back of head and c/o neck pain Durationdaily Characteristics Dull, increased with movement Aggravating Factors Non- radiating, dull and associated with neck pain Relieving Factors Movement of head TreatmentTylenol for headache Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Medication (Rx, OTC, or Homeopathic) DosageFrequency Length of Time Used Reason for Use Proventil 90 mcg, inhaler As needed30Asthma exacerbation- Rescue inhaler for asthma exacerbation Flovent Patient unaware of exact dosage daily30Asthma management Tylenol650mg as needed by As needed30For headaches

S: Subjective

Information the patient or patient representative told you

mouth Advil600 mg as needed by mouth As needed30For menstrual cramps Metformin 500 mg twice a day by mouth Twice a day30Patient states she does not take this any more 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.Should include: the accident MVA, should pertain to the Chief complaint, 15mile accident in parking lot, wearing seat belt, rear end fender bender.Was not drinking alcohol.Asthma dx age 2.5 yrs old Diabetes dx at 24yrs old, Denies surgical history Past Medical History: DM type 2; Asthma: diagnosed at age 2.5years, HTN Vaccinations: Reports being up to date with Pneumonia vaccine: 1 year ago; Tetanus Vaccine: 1 year ago. No current with Flu vaccine. Reports that all childhood vaccines were received.

Past surgical history: None

Past hospital admissions: 3mo since last physical and checkup.; apx. 5 hospital admissions for asthma exacerbations; Last admission related to asthma was when patient was 16.Reports all Immunization are up to date

Last Flu vaccine: 5 or 6 years ago per patient, declines at this time

Last Tetanus booster: 1 year ago Meningitis Vaccine at 19yrs old.

Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.

Marital Status: Single.

Current birth control methods: Abstinence; History of PO birth control (Last used 2 years ago)

Occupation: Works as a supervisor at Mid-American copy

Education: attending college to obtain a bachelor’s degree in accounting.

Living arrangements: Lives with mother and sister

father deceased from car accident.

Hobbies: Enjoys reading watching tv series and documentaries

Brother lives with fiancée.

Religion: Active in local church.

Substance use: Denies tobacco use and current recreational drug use. Reports cannabis use 3 years ago.Drinks alcohol (approx twice a month) socially with friends. Last alcoholic beverage, 3 weeks ago.

Denies tobacco use.Drives and always uses a seatbelt, working smoke detector in house.Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.Father- died from accident. Type 2 diabetes, high cholesterol and blood pressure.Mother-Living, high cholesterol, and blood pressure paternal grandfather- colon cancer, high blood pressure, diabetes, high cholesterol brother's- obesity

Mother: Hypertension, High cholesterol

Father: (Deceased) at age 58 in mva: HTN, Type II DM, high cholesterol Paternal Grandfather: (Deceased): Colon CA. Type II DM, HTN, high cholesterol

Paternal Grandmother: HTN, high cholesterol

Maternal Grandmother: HTN, high cholesterol

Maternal Grandfather: (Deceased): Cardiovascular Accident. HTN, High cholesterol

Sister: Asthma

Brother: No health history

Maternal grandmother- stroke, high blood pressure and cholesterol.paternal grandfather-passed away paternal grandmother's blood pressure, high cholesterol.sister's-asthma.Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.Constitutional If patient denies all Skin If patient denies all HEENT

If patient denies all symptoms for this system, check here: ☐

symptoms for this system,

check here: ☐

symptoms for this

system, check here: ☐

☒Fatigue reports feeling tired ☐Weakness Click or tap here to enter text.☐Fever/Chills Click or tap here to enter text.☐Weight Gain Click or tap here to enter text.☒Weight Loss Click or tap here to enter text.☐Trouble Sleeping Click or tap here to enter text.☐Night Sweats Click or tap here to enter text.

☐Other:

Click or tap here to enter text.☐Itching Click or tap here to enter text.☐Rashes Click or tap here to enter text.☐Nail Changes Click or tap here to enter text.☒Skin Color Changes color discoloration around the neck

☒Other:

ance ☐Diplopia Click or tap here to enter text.☐Eye Pain Click or tap here to enter text.☐Eye redness Click or tap here to enter text.☐Vision changes states she has blurred vision when she reads ☐Photophobia Click or tap here to enter text.☒Eye discharge watering eyes around cats ☐Earache Click or tap here to enter text.☐Tinnitus Click or tap here to enter text.☐Epistaxis Click or tap here to enter text.☐Vertigo Click or tap here to enter text.☐Hearing Changes Click or tap here to enter text.

☐Hoarseness Click or tap here to enter text.☐Oral Ulcers Click or tap here to enter text.☐Sore Throat Click or tap here to enter text.☐Congestion Click or tap here to enter text.☒Rhinorrhea runny nose around cats

☐Other:

Click or tap here to enter text.Respiratory If patient denies all symptoms for this

system, check here: ☐

Neuro If patient denies all symptoms

for this system, check here:

☐ Cardiac and Peripheral Vascular

If patient denies all symptoms for this system, check here: ☐

☐Cough Click or tap here to enter text.☐Hemoptysis Click or tap here to enter text.☐Dyspnea Click or tap here to enter text.☒Wheezing with asthma exact ☐Pain on Inspiration Click or tap here to enter text.☐Sputum Production

☐Other: Click or tap here to enter

☐Syncope or Lightheadedness Click or tap here to enter text.☒Headache presents today for headache due to mva ☐Numbness Click or tap here to enter text.☐Tingling Click or tap here to enter text.☒Sensation Changes loss in the ☐Speech Deficits Click or tap here to enter text.

☐Other: Click or tap here to

☐Chest pain Click or tap here to enter text.☒SOB with asthma exac ☐Exercise Intolerance Click or tap here to enter text.☐Orthopnea Click or tap here to enter text.☐Edema Click or tap here to enter text.☐Murmurs Click or tap here to enter text.☐Palpitations Click or tap here to enter text.☐Faintness Click or tap here to enter text.☐Claudications Click or tap here to enter text.☐PND Click or tap here to enter text.

☐Other: Click or tap here to

enter text.