Soap Note Assignment Hca 220

Topics: Red blood cell, Sickle-cell disease, Medical terms Pages: 3 (624 words) Published: September 29, 2011
Axia Material

Create three SOAP notes using correct medical terminology from the patient information in Appendix C.

* Organize the information correctly
* Format the SOAP notes
* Revise language where necessary

Post your paper as a Microsoft® Word attachment.

Patient One – Chapter 6

Soap Notes
Date:| 09/26/2011| Chart:| 001| Age:| 22|
Name:| Jane Doe| Date of Birth:| 02/11/89| Sex:| F|

S:| Patient has sever lower back pain that was constant for 5 days, she hasn’t been eating, no vomiting after eating, also has been having headaches. Bowel signs and sounds are good. Patient isn’t on any meds currently. Has been diagnosed in the past with sickle cell anemia.| CC:| Lower back pain for five days.|

History of Present Illness: regular headachesPast Medical History: Sickle cell anemia| O:| Pt. physical exam of body is fine. Pt has normal, regular skin color and is very alert. Discovered pain is present in lower abdomen over spine. Blood work and labs were done. Ordered IV with fluids. Blood work showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,00, segs 65.9, lymphs 27, monos 3.4| Vital Signs:| BP:| 140/60| PR:| 22| RR:| 38| T:| .99 °F| W:| Lbs.| | |

A:| Patient is having a sickle cell crisis.|
Dx:| Sickle cell crisis|
P:| Pt. will be admitted to hospital, IV will be administered with fluids and pain meds, will return in the morning to see pt. again.|

Patient Two – Chapter 7

Soap Notes
Date:| 09/26/2011| Chart #:| 012| Age:| 26|
Name:| John Doe| Date of Birth:| 02/02/1984| Sex:| M|

S:| Pt. states that he has been having pain on his bottom area. Previously he went to the ER and had the area opened for drainage. No other complaints.| CC:| Pain on bottom buttock area|
History of Present Illness: DiabetesPast Medical History: Past history of diabetes| O:| Physical exam of pt. was normal with no...
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