NR 509 SOAP Note Week 1_NR509 SOAP Note week 1:Chamberlain College Of Nursing.

SOAP Note Template

Initials: TJ Age: 28 Gender: Female

Height Weight BP HR RR Temp SPO2 Pain Allergies



90 kg 142/


86 19 101.1 f 99% 7/10 Medication: Penicillin

Food: Denies

Environment: Cats, dust

 History of Present Illness (HPI)

Chief Complaint (CC) “I got this scrape on my foot a while ago, and I thought it would heal up on its

own, but now it's looking pretty nasty. And the pain is killing me!”

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 1 week

Location Plantar surface of right foot

Duration Daily

Characteristics She reports that ankle swelling and pain have resolved but that the bottom of

the foot is increasingly painful. The pain is described as “throbbing” and “sharp”

with weight bearing.

Aggravating Factors Weight bearing, walking, standing

Relieving Factors Tramadol

Treatment TJ sought treatment from the emergency department. She received a

prescription for Tramadol, She reports cleaning the wound twice a day and

putting Neosporin and a bandage on the area.

Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.


(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time

Used Reason for Use

Tramadol 50 mg TID prn Daily for 1 week Pain

Albuterol inhaler 90 mcg/spray 2-3 times per week prn weekly Wheezing

Acetaminophen 500-1000 mg prn Monthly headaches

Ibuprofen 600 mg prn Monthly Menstrual cramps

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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.

S: Subjective

Information the patient or patient representative told you

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Asthma diagnosed at age 2.5, last hospitalized “in high school”, never intubated. Diabetes Mellitus type two, diagnosed age 24. Denies taking

medication for Diabetes, denies keeping track of her glucose. Denies surgies. Immunizations: tetanus: within the past year, Influenza: denies,

Human paoillomavirus: denies, reports all of her childhood shots are up to date abd she received all shots needed for college.

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.

Never married. No Children. Moved out after high school. Currently lives with mother and sister. Moved back in after father died to help mother.

Works at Mid-American Copy and Shipping as a supervisor. 32 hours a week. She is a part time college student; she has 2 semesters left in order

to earn her bachelor's degree in accounting. She plans to get a job at an accounting firm after graduation. She has a car and a cell phone. She has

health insurance through work but is unsure of what it covers. She likes to go to bar and clubs with her friends. She like to watch tv, spend time with

friends, attend bible study, volunteer at church, and dance. She has a strong support system. She generally gets stressed when she has too much

to do but currently reports no stressors. Reports smoking marijuana at age 15 until age 21. Denies any other drug use. Reports occasional alcohol

consumption 2-3 times per month. Reports only a "few" drinks when she goes out. She denies driving while intoxicated. Reports drinking 4 diet

sodas a day. Denies foreign travel. Denies pets. Denies current relationship. Last relationship 2 years ago. Future plans to live independently, have

a relationship, family, and job growth. Safety: Has smoke detectors in the house, wears a seat belt, does not ride a bike, occasionally wears

sunscreen, gun lucked up in mothers’ room.

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


• Mother: age 50, hypertension, elevated cholesterol

• Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes

• Brother (Michael, 25): overweight

• Sister (Britney, 14): asthma

• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol

• Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol

• Paternal grandmother: still living, age 82, hypertension

• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes

• Paternal uncle: alcoholism

• Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

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 Skin HEENT

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Version 2021
Category Exam (elaborations)
Included files pdf
Pages 7
Language English
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