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    Soap Template

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    rohit

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Soap Template

    Uploaded by

    rohit
    131 views3 pages

    Original Title

    SOAP TEMPLATE.docx

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    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    131 views3 pages

    Soap Template

    Uploaded by

    rohit

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    NAME:___________________________ M/F AGE:________ DOA:________

    Admitting Dx:____________________________________________________________________

    Over night
    __________________________________________________________________________________
    complaints

    Fever Vomits (amt., colour, Stool (change, colour,


    Urine (difficulty, burning,
    (in/outside); content, post- diarrhoea, constipation, SOB
    frequency, colour)
    Temp prandial) flatus)

    VITALS

    BP Temp RR HR SpO2 RBS

    Physical Exam

    General How pt. looks, position, CP


    distress, catheter (amt.), IV
    line (amt + drugs), Chest
    tube, O2 Masks (amt); other
    H
    Size, shape, lumps, pain

    E MM< Conjunctiva,
    exophthalmos, discharge,
    pain
    E
    Blockage, discharge, bumps

    N MM, blockage, pain,


    discharge
    T Neck pain, Trachea midline,
    lymph nodes/ masses
    Resp BAE, Adventitious
    Crackles, wheezes

    CVS Cap refilS1, S2,


    Murmurs,PMIl, Peripheral
    pulses

    ABD Inspect (Scars, wounds,


    surgical wounds, shape,
    moves with inspiration)
    Auscultate, Percuss, Palpate
    (organomegaly)
    EXT ROM, scars, wounds,
    cyanosis, sensation
    CNS Conscious, alert, oriented?
    To themselves & you, Place,
    Time
    Maaaaybe reflexes
    NAME:___________________________ M/F AGE:________ DOA:________
    Admitting Dx:____________________________________________________________________

    MEDICACTIONS LAB RESULTS

    IMPRESSION/ ASSESSMENT:
    _______ Year Old Male/Female with a PMH of _________________________________________,
    Currently diagnosed with __________________________________________, _________ days pre-
    op/post-op/ of admission, currently stable/ unstable.

    This part below is only needed if asked

    PLAN:
    DIET_______________________________________________________________________
    VITALS check q___hrs. RBS check q______hrs.
    IV FLUIDS (what+ amt + duration) ______________________________________________
    __________________________________________________________________________________
    __________________________________________________________________________________
    __________________________________________________________________________________
    MEDICATIONS (Form, Name, Dosage, Route, Amt. Daily, Duration)
    ________________________________________ _____________________________________
    ________________________________________ _____________________________________
    ________________________________________ _____________________________________
    DRESSING: (type, freq.)_____________________________________________________________
    LABS: ____________________________________________________________________________
    IMAGING: _______________________________________________________________________
    NAME:___________________________ M/F AGE:________ DOA:________
    Admitting Dx:____________________________________________________________________
    Cath, NGT, Chest Tube, O2__________________________________________________________
    REFERRAL:______________________________________________________________________

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