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Posted: May 1st, 2022
Nursing Title: Comprehensive SOAP Note #3
Nursing
Title: Full SOAP Bear in mind #three
Number of sources: 4
Paper instructions:
Practicum Experience – Full SOAP Bear in mind #three
After ending this week’s Practicum Experience, Assessment the Full SOAP Bear in mind Exemplar and Template on this week’s Belongings, and replicate on a affected one that launched with musculoskeletal issues or ache. Describe the affected particular person’s non-public and medical historic previous, drug treatment and coverings, and follow-up care.
All SOAP notes ought to be signed and each internet web page ought to be initialed by your preceptor. Should you submit your SOAP Notes, it is best to embrace the entire SOAP Bear in mind as a Phrase doc and pdf/images of each internet web page that is initialed and signed by your preceptor. It’s a must to submit your SOAP Notes using SAFE ASSIGN.
Age 73 Male , J.S.
DX HTN, Arthritis,
Ambulate with cane
Essential indicators 134/76 18 97.three 97% O2 SAT HT 5’6 217 WT
Ache treatment hydrocodone 5/325mg every 6 hours as needed for ache, ache stage reported three after med discount and differ 6to eight on most days
Affected particular person obtained flu immunization
No allergic reactions
No pores and pores and skin openings , poor turgor
Resp , no SOB lungs clear on asculation
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