Medical Phenomenology: Soap Notes
Axia Material
SOAP Note
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 …show more content…
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. | | …show more content…
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 problems. Abdomen is fine, checked under neck area and there’s no swelling, also no visible swelling in hands or feet. Observes the pt. bottom and sees the drained pimple which still has drainage coming from it. | Vital Signs: | BP: | 115/80 | PR: | 90 | RR: | 15 | T: | 98°F | W: | 215lbs | | | A: | Patient still has drainage coming from bottom buttock area after it was cut open at the ER previously. | Dx: | Infected site on buttock. | P: | Will make a small incision on lower area of buttock to allow proper drainage. Inform pt. of the care of the area when he goes home and prescribe pt.meds. |
Patient Three – Chapter 14
Soap Notes Date: | 09/26/11 | Chart #: | 013 | Age: | 45 | Name: | Janet Doe | Date of Birth: | 04/12/1966 | Sex: | F |
S: | Pt. states that she has a history of diabetes but hasn’t seen a physician in 3 yrs. due to lack of medical insurance. She states that she hasn’t been feeling good. She isn’t a smoker nor does she drink.
SOAP Note
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 …show more content…
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. | | …show more content…
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 problems. Abdomen is fine, checked under neck area and there’s no swelling, also no visible swelling in hands or feet. Observes the pt. bottom and sees the drained pimple which still has drainage coming from it. | Vital Signs: | BP: | 115/80 | PR: | 90 | RR: | 15 | T: | 98°F | W: | 215lbs | | | A: | Patient still has drainage coming from bottom buttock area after it was cut open at the ER previously. | Dx: | Infected site on buttock. | P: | Will make a small incision on lower area of buttock to allow proper drainage. Inform pt. of the care of the area when he goes home and prescribe pt.meds. |
Patient Three – Chapter 14
Soap Notes Date: | 09/26/11 | Chart #: | 013 | Age: | 45 | Name: | Janet Doe | Date of Birth: | 04/12/1966 | Sex: | F |
S: | Pt. states that she has a history of diabetes but hasn’t seen a physician in 3 yrs. due to lack of medical insurance. She states that she hasn’t been feeling good. She isn’t a smoker nor does she drink.