Tina jones (T.J) Neurology. SOAP Note Template. Contains Subjective informations; History of Present Illness (HPI); Current Medications; Past Medical History (PMHx); Family History (Fam Hx); Review of Systems (ROS).

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SOAP Note Template Initials: TJ/ address 9647 Jeffers St. Spring Hill Fl 34606 Age: 28 Gender: female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 88 kg 139/ 87 82 16 98.9 99% 3/10 ... Medication: Penicillin Food: Na Environment: Cats History of Present Illness (HPI) Chief Complaint (CC) Headaches and neck stiffness 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 2 days ago Location Neck and head Duration 2 days Characteristics Head aches throbbing and neck stffness Aggravating Factors Car accidient two days ago Relieving Factors Tylenol Treatment Tylenol for pain 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 UsedTime Reason for Use Proventil 2 puffs 2-3 time a week Since 2 years old Asthma Tylenol 500 mg 2 tabs every 6 hrs prn headaches Two days Headaches Proair Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Flexeril 10mg Q4 hrs prn 10days Muscle spasms Metformin 500mg 1 tab q 12 hours indefinately Diabetes 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. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Solomon, S., Eisnstein, A.(2019). Headache Unit, Montefiore Medical Center, Albert Einstein College of Medicine retrrived from https://www.brainline.org/article/headaches-after-head-injuries Staehler, R., Stiff Neck Causes, Symptoms, and Treatment, (2017). Spine Health retrieved from retrieved from https://www.spinehealth.com/conditions/neck-pain [Show More]

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