Nursing
Title: Complete SOAP Be aware #three
Variety of sources: four
Paper directions:
Practicum Expertise – Complete SOAP Be aware #three
After finishing this week’s Practicum Expertise, assessment the Complete SOAP Be aware Exemplar and Template on this week’s Assets, and replicate on a affected person who introduced with musculoskeletal problems or ache. Describe the affected person’s private and medical historical past, drug remedy and coverings, and follow-up care.
All SOAP notes should be signed and every web page should be initialed by your preceptor. If you submit your SOAP Notes, it’s best to embrace the whole SOAP Be aware as a Phrase doc and pdf/photos of every web page that’s initialed and signed by your preceptor. You have to submit your SOAP Notes utilizing SAFE ASSIGN.
Age 73 Male , J.S.
DX HTN, Arthritis,
Ambulate with cane
Important indicators 134/76 18 97.three 97% O2 SAT HT 5’6 217 WT
Ache medication hydrocodone 5/325mg each 6 hours as wanted for ache, ache stage reported three after med reduction and vary 6to eight on most days
Affected person obtained flu immunization
No allergic reactions
No pores and skin openings , poor turgor
Resp , no SOB lungs clear on asculation
