NRSG 351 SOAP NOTE TEMPLATE Assignment

Identifying info: initials, age, gender

SUBJECTIVE

Chief Complaint (CC): Just 1 word or 1 sentence. Details go under HPI.
History of Present Illness (HPI): Be very specific about the CC. Include all pertinent OLD CARTS info
Past Medical History (PMH): Any pertinent diseases/events in the past and current diseases that are
not the CC. OLD CARTS the disease/event. Include surgeries and hospitalizations.
Family History (FH): List the disease and age at diagnosis for close relatives.
Medications: State med, dose, how long the patient has been taking it and any side effects.
Allergies: List them, noting any treatment or consequences from allergy
Social History: Describe living situation, education, job, ADLS including exercise and diet. List past and
present habits of smoking, drinking, recreational drugs.
Review of Systems (ROS): Pertinent positives (OLD CARTS) and negatives for the system you chose.

OBJECTIVE

Vital Signs List full VS
General Survey Give a 2-3 sentence overview of your impression of this patient.
Physical Exam: Document your exam for pertinent systems (but also give quick assessment for other
systems.
HEENT:
Cardiac:
Pulmonary:
Abdomen:
GI/GU:
Neuro:
Musculoskeletal:
Skin:
Labs:
IV:

ASSESSMENT

List any positive findings, starting with CC
1. CC (diagnosis)—-what are you assessing for and caring for in this hospitalization
2. Any positive Pertinent PMH
3. Pertinent FH
4. Positive Pertinent ROS
5. Any knowledge deficit or need for change in diet, lifestyle, etc. EX: obesity or smoking
PLAN
List your plan to address the findings under assessment
1. What are you doing about the CC?
2. Any teaching related to prevention, symptoms, lifestyle, etc.
3. Medications needs/teaching
4. Tests/procedures needs/teaching
5. When do you want the patient to follow up/RTC, referrals

PLAN

You are the nurse caring for the following patient who was admitted to the hospital on 1-30 to a medical/surgical unit.

1. Name: Helga Hufflepuff, 67 year old female
2. Admitted to hospital straight from her primary MD office at 0800 on 1-30 with wound infection in left lower leg (MRSA +) and on contact isolation (Chief Complaint)
3. She uses home oxygen 2 LPM via nasal cannula PRN SOB for past 2 years and takes Acetaminophen 500mg PO every 6 hours as needed for back pain.
4. Heart rate and rhythm are within normal limits and regular
5. She has allergies to shellfish(hives), iodine (hives) and Levaquin (facial swelling).
6. She has history of degenerative spine disease and has difficulty ambulating
7. She complains of mild pain in her back (not admitting diagnosis) and states it is throbbing and radiates to legs.
8. Peripheral IV (20g in left lower forearm)
9. History of COPD for 15 years as well as intermittent confusion for past 2 years
10. Heart rhythm regular, S1/S2 noted. No edema, +2 pulses in all extremities.  Capillary refill < 2 seconds
11. Admitting provider:  Poppy Pomfrey, MD
12. Vital signs: BP 119/67, HR 92, RR 25, temp 100.2F, O2 Sat 95% weight is 157 lbs and she is 5′ 7″
13. Left lower leg (lateral side) wound 8cm x 12 cm and 0.5cm deep, draining dollar-bill size amount of purulent, green drainage on bandage, foul odor present, redness and swelling noted peri-wound.  Wound base is covered with necrotic tissue which is tan in color.  Skin on body is otherwise clean, dry and intact.
14. CBC:  all within normal limits except WBC’s 15,000
15. Client states the wound has made it difficult for her to bathe and ambulate
16. Her mother diagnosed with type 2 diabetes at age 63
17. She states that her Left leg wound began 4 days ago (started as a scratch and then became larger, draining green thick drainage with foul odor) and she states the wound is painful to touch
18. Client denies fever at home and denies any skin lesions or concerns.  She also denies itching or rash.
19. She is awake and alert with occasional confusion
20. Client attempted to apply OTC antibiotic ointment on leg wound when it first started but states “it just made it worse”
21. She smokes ½ pack per day (for 25 years)
22. Nothing has helped relieve her wound symptoms at home, and sought treatment from her primary MD for the first time today
23. Physician orders include:
    1. Meropenem (antibiotic) 500mg IV every 8 hours
    2. Acetaminophen 500mg PO every 6 hours PRN back pain
    3. Regular diet
    4. Administer O2 via nasal cannula to keep saturation between 92-96%
    5. Wound care BID: Clean with NS, apply antibiotic ointment, cover w/gauze