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SOAP Notes

Three SOAP notes were created summarizing information from patient cases in the document. Each SOAP note follows the standard format of Subjective (S), Objective (O), Assessment (A), and Plan (P) sections. Key details included a sickle cell crisis, a sore filled with fluid on the bottom, and conditions related to untreated diabetes such as numbness in the hands and feet. Treatment plans involved medication, further testing/monitoring, and patient education.

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emmag79
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802 views

SOAP Notes

Three SOAP notes were created summarizing information from patient cases in the document. Each SOAP note follows the standard format of Subjective (S), Objective (O), Assessment (A), and Plan (P) sections. Key details included a sickle cell crisis, a sore filled with fluid on the bottom, and conditions related to untreated diabetes such as numbness in the hands and feet. Treatment plans involved medication, further testing/monitoring, and patient education.

Uploaded by

emmag79
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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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: 9/30/2011 Name: Fannie May Chart 111 #: Date of 3/11/78 Birth: Age: 27 Sex: F

S:

Patient presents with back pain at level 10 with no relief for 5 days. Normal bowel. No appetite, no vomiting. Mild headache. Normal bowel.

CC:

Back pain level 10 no relief for 5 consecutive days.

History of Present Illness: Level 10 back pain with headache Past Medical History: sickle cell anemia

O:

No physical symptoms, alert and speaking clearly. Skin color normal. White blood cells 4300, hemoglobin 13.1 g/dl, hematocrit 39.9%,platelets 162,000,segs 65.9,lymphs 27, monos 3.4

HCA/220r7

Vital Signs:

BP:140/60

PR:22

RR:38

T: 99F W: 120 lbs

A:
Patient is having sicle cell crisis.

Dx:

Sickle cell crisis

P:
Patient will be administered IV pain medication and fluids, and admitted. Dr. will return in the am to see patient again.

Patient Two Chapter 7

Soap Notes
Date: 9/30/2011 Name: Jack Bequick Chart 222 #: Date of Born Feb.2, 1984 Birth: Age: 26 Sex: M

S:

Patient describes sore on his bottom full of fluid. No other issues.

CC:

Sore filled with fluid on bottom

History of Present Illness: Seen in ER, sore drained

HCA/220r7

Past Medical History: Diabetes

O:
Physical exam showed sore on bottom still filled with fluid, drained once in ER, but no other physical symptoms found during physical exam. Blood sugar 200 range.

Vital Signs:

BP:

PR: 90 RR 15 T: 98F W: 215 lbs

A:

Sore on bottom

Dx:

Sore on bottom

P:
Patients sore will be drained again, patient will be educated on care of sore, and prescribed medication.

Patient Three Chapter 14

Soap Notes
Date: 9/30/11 Name: Ben Gee Chart 333 #: Date of Birth: Age: 45 Sex: F

S:
Patient has not had medical insurance for 3 years, and now has insurance so decided to get checked out because she has diabetes. She has not been controlling her diabetes. She bases her levels on how she feels because stated that testing with the machine is painful. She has not been feeling well.

HCA/220r7

CC:

Conditions and issues related to untreated diabetes

History of Present Illness: Past Medical History:

O:
Physical exam reveals condition due to numbness of her hands and feet that is caused by diabetes. Discoloration of skin. No other physical symptoms present. Sugar was tested and at 152.

Vital Signs:

BP: 126/86 PR: 104 RR: 16 T: 98.6F W: 185lbs

A:
Condition related to untreated diabetes.

Dx:

Conditions related to untreated diabetes. Numbness of hands and feet

P:

Physician prescribes medication for diabetes, patient will return once a month, physician educated patient and tells her she need to control diabetes.

HCA/220r7

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