Cough soap note. He also complained of feeling tired.

Cough soap note PMH: Full-term birth, no chronic illnesses. SOAP NOTE Exemplar - Detailed CHIEF COMPLAINT (CC): “I’ve been coughing a lot and I feel short of breath” HISTORY OF PRESENT ILLNESS (HPI): Sharon is a 58 year old female who presents to the clinic today complaining of a cough that has been increasing over the past week, and seems worse at night. Recent upper respiratory infection (URI) resolved Below are SOAP note examples and walkthroughs of how you can effectively and quickly write a SOAP note following the SOAP note outline depending on your needs: Subjective. J. SOAP note 2 - Soap note; ABD SOAP; NURS550 - Focused Soap Note 1; Irvin et al. 2017 - N/a; Related documents. com Here is an example of a SOAP note for a patient with COPD: Subjective: The patient is a 65-year-old male who presents to the clinic with complaints of shortness of breath, cough, and wheezing. The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. FNP 592. Chief Concern (CC)/Reason for Visit Persistent cough x1 week. There has been no fever, headache, earache, chest pain, dyspnea Explore our comprehensive collection of 10 common Registered Nurse SOAP note examples, designed to enhance your clinical documentation skills. She had recently returned from a cruise where she spent time in casinos. I have been Kallendorf-SOAP #3 note 4. The patient appears calm and cooperative. The patient appears with no developmental deficiencies. Jane Chen, a 45-year-old Asian female, presents with a one week history of productive cough with yellow/green sputum and pink streaks, shortness of breath, wheezing, and fevers over 101F. This section Focused Exam: Cough Results | Turned InHealth Assessment - Remediation/Refresher - January 2021, CCE 705 and 701. Onset 2 days ago Location Pain to back of neck both sides Crown of head & back of the Denies cough. Subjective Information Chief Complaint: Patient reports a cough lasting four to five days. Chief complaint and History of present illness: 24-year-old male presents to the clinic for complaints of left ankle pain. docx - Episodic Visit Pages 5. docx - Free download as PDF File (. CHIEF COMPLAINT: Sore throat. University Of Georgia. Subjective CC: "I've been feeling sick. Chamberlain College of Nursing. He has had congestion and coryza without cough for about one week. WK9Assgn 1 The patient is a 70 year old Caucasian female that SOAP #1 – COVID-Student Name: Course: Care of the Adult II - Practicum. It is most commonly used to explore pain but can be applied to other symptoms, although some of the elements of Patient Information: K, 65 year old, female, insured Subjective Data CC: "cough" HPI: Presents with cough that started a week ago is not getting better, wakes her, cough now causing her chest to hurt, points to area on right side that she reports it hurts every time she takes a deep breath. Learn how to write a SOAP note for a patient with cough and congestion, likely due to viral upper respiratory infection. He describes cough as “gurgly and watery. Other than a fever earlier in his History of presenting complaint. I have been coughing a lot. The cough is 2 Shadow Health Documentation: Danny Rivera Case Study SOAP Notes Subjective Data Chief Complaint The patient complained of feeling sickly and coughing a lot. Danny Rivera is an 8-year-old boy presenting with a Cough 786. SOAP note. pdf), Text File (. This transcript also has a differential diagnosis. Reports cough is worse at night Denies smoking Reports being exposed to secondhand smoke through father Reports he doesn't know what triggers the cough. J. Environment: Click or tap here to enter text. On examination, she was well-appearing but had expiratory SOAP Note Form S/ Identifying Information: (initials, age/DOB, gender, reliability) M. She has had raw throat with cough without other concurrent sore throat. On examination, his throat is very erythematous with inflamed tissues and enlarged tonsils. The mother reports that the son's cough is intermittent during the day but is more SOAP Note Example NP Pediatric Patient, Example SOAP Note Nurse Practitioners Teen Patient, Nurse Practitioner SOAP Note Example. 5. SOCRATES. pdf; Shadow Health Chest Pain Subjective Data; Shadow Health Health History Tina Jones Advance Assessment Subjective Data Collection; Tina Jones soap note - Soap note; Week 4 Skin Assignment Picture 2 (Stretch Marks) Focused Episodic SOAP Note for Sore Throat HPI: This is a 45-year-old African American female who presents here today with complaints of cough 8/10. docx. 2 Allergic sinusitis 477. WK6Assgn 1Torres R DCE Provider Notes - Focused Exam: Cough, Danny Rivera Subjective Danny is an 8-year-old male patient who is brought to the clinic by Abuela with chief complaint of coughing of cough that has lasted for five days. ” History of Present Illness (HPI): Case presents with a cough that started 5 days ago. This guide covers a wide range of conditions frequently encountered in nursing practice, including post-operative care, wound care, diabetes management, respiratory assessment, pain management, cardiac monitoring, Focused Note Subjective information: Date of encounter: February 21 st, 2020 Patient Name or initials: Danny Rivera Informant: The informant is the patient, who is a reliable historian. States is more tired, easily winded when walking, decreased energy. 43 y/o black female CC: “I am here today because I have a cough and sore throat. Acute right otitis media Family Medicine SOAP Outpatient Progress Note. present at visit Chief Complaint (CC): • Patient C/O sore throat, headache, fever 104. Chief Complaint (CC): “My abuela brought me here because I’ve been feeling sick. HSCI 1301. Age: 50yrs. 9 Plan: Office visit, Established patient 992. Return to Canvas to complete your SOAP note for this assignment. Pediatric Soap Note on Pulmonary Chronic Condition Patient Initial: K. B. 14 Asthma and cough- Provided couseling related to asthma which included teaching correct technique of inhaler and return demonstration by patient. Soap_Note___Cough. Other N/A A: ASSESSMENT AND DIAGNOSIS DIAGNOSIS ICD-10 CODES PRIORITIZE DIAGNOSIS 1. WEEK 4 SOAP NOTE Annual physical. comes into the clinic complaining of a 4-week-old productive cough and dyspnea (shortness of breath). Common Illnesses Across Lifespan 95% (146) More from: View 590A Pediatric SOAP Note Cough. txt) or read online for free. Patient is otherwise healthy. 1 History of Present Illness (HPI): • Patient C/O sore throat, headache, fever 104. Date: 02/08/2018. Have you been around anyone sick? EDUCATE Hand hygiene is very is very important. R. She took medication but nothing took affect which then progressed to the present symptoms. B. Patient reports a productive cough with "slimy, clear" sputum. Name: T. ” Hx of present illness: The patient is a 45 ‐ year ‐ old dispute mediator with cough productive of yellow ‐ green and occasional blood ‐ tinged sputum for a week, fever, mild shortness of breath and occasional Clinical SOAP Note Pediatric Heather Curtis Subjective Data Patient Demographics: • SNP, 11-year old Caucasian male • Pts. docx from NSG MISC at Herzing University. docx from GNRS 590A at Azusa Pacific University. SORE THROAT AND COUGH 2 Sore Throat and Cough Soap Note Date: 21/01/2020 Patient’s Name: Jackson Smith Age: 4 years Sex: Male Source of Reliability: mother and observational data CC: Sore throat and Cough Subjective Data HPI: Jackson Smith is a four-year-old Hispanic male that was accompanied by his mother today since he has been SOAP Note on Acute Bronchitis Student Name: Course: NSG6330/NSG Patient Name: Mrs. denies fever, chills, docx (3) - Free download as Word Doc (. He also complained of feeling tired. HPI: Progressive flu-like symptoms (sore throat, nasal congestion, HA, body aches) started 5 days ago, with new . NR 602 Week 3 IHuman Katherine Harris GOOD QUESTIONS. Julie Collier / 25 Jan 2019 Complete Score Failed items Actions Patient name Leslie Grant Prior to this, the patient says she had a common cold and whooping cough for weeks. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. I have been coughing a lot and I feel kind of tired. View More. Cough reportedly worse at night. Lawrence Weed in the 1960's at the University of Vermont as part of the Problem-orientated medical record (POMR). S. 2 c 98. Module 8 SOAP Note. The patient reports chest discomfort 7/10 severity and chills X2 a day. Danny Rivera SOAP - Free download as Word Doc (. SOAP Note Week TwoUnited States University. This guide covers a wide range of conditions frequently encountered in nurse practitioner practice, including hypertension, type 2 diabetes, upper respiratory infection, asthma exacerbation, urinary tract infection, migraine SOAP Note: S: 30 y/o man complains of sore throat for the past 3 days. W 42 y/o Black Aquí nos gustaría mostrarte una descripción, pero el sitio web que estás mirando no lo permite. Patient In a nurse practitioner SOAP note, the Objective section (O) captures measurable, observable, and factual data obtained during the patient’s examination. 8-year-old Latino male patient presents today with abuela (grandmother) for c/o cough the past 5 days, sore throat since yesterday along with right ear pain. He denies any headache, dizziness, fever, sputum, chest pain, , abdominal pain or breathing problems. His cough does not get worse when he is active. 1 Danny Rivers cough SOAP note. He also reports general fatigue Episodic/Focused Note for Focused Exam: Cough; Document: Episodic/Focused SOAP Note Template (Word document) Week 5 – Focused Exam: Cough Danny Rivera. He is here for poor control of his asthma. Advanced Health Assessment 97% (36) 7. On questioning, it is probably due to noncompliance because he had some insurance problems. Solutions Available. V. Model Note. No fever. Document: Nursing Notes Student Documentation Subjective 8 Years old, male, Danny Rivers cough SOAP note. SUBJECTIVE: The patient is a (XX)-year-old male we are seeing for the first time. Assessment. DANNY RIVERA COUGH SOAP NOTE 4 Physical exam: General survey-The patient a appears with persistent cough. He will be advised to take deep breaths and cough several times each hour to loosen up mucus and get it out of his Respiratory hygiene: Instruct on proper hand hygiene and emphasize the importance of wearing a mask and covering the mouth when coughing to prevent the spread Cough and chest congestion with body aches and chills transcribed medical transcription SOAP note example report for reference by medical transcriptionists. J Age: 12 Gender: Female SUBJECTIVE DATA Chief Complaint: "I have a productive cough that's causing shortness of breath" History of Present Illness: A 12-year-old African American girl named K. ” Reports coughing “every couple minutes” and feeling tired due to disruption of Explore our comprehensive collection of 10 common Nurse Practitioner SOAP note examples, designed to enhance your clinical documentation skills. WK 5 Focused Note Cough Danny Rivera; Tina Jones soap note - Soap note; Week 4 Skin Assignment Picture 2 (Stretch Marks) Focused Episodic SOAP Note for Sore Throat; Related documents. He also reports mild throat sores. ” HPI: A 32 y/o White female comes to the clinic with an 11-day history of cough, Patient presents with a cough beginning 5 days ago. Immunizations: Up to date, including PCV13 and influenza. Denies recent contact with sick and recent travel. History of PACE UNIVERSITY COLLEGE OF HEALTH PROFESSIONS LIENHARD SCHOOL OF NURSING DEPARTMENT OF GRADUATE STUDIES 1 NURS 642 SAMPLE SOAP NOTE Date: 10/09/2024 15:20PM Patient’s Name: Stephen/Sarah Miller DOB:03/03/1964 CHIEF COMPLAINT: “I’m here with this cough; it just seems to be getting worse” HISTORY OF Enhanced Document Preview: 1 Pediatric SOAP Note Wendolly Santos Department of Nursing, University of Arkansas NURS 4143: Child and Family Practicum Dr. Time: 1030. 2 Sore Throat SOAP Note Patient Information: Patient #3, 25-year-old, Caucasian male Subjective CC (chief complaint)- “I have a sore throat since the last 4 days, and I feel tired and achy” HPI: Patient # 3 is a 25-year-old Caucasian male who visited the facility with report of: Location: throat Onset: 4 days ago Character: sore, scratchy Associated signs and symptoms: Danny Rivera Episodic Visit Chief Complaint: Reports “I have a watery and gurgly cough for the past 5 days” History of Present Illness: States has been coughing x 5 days, no fevers, and clear nasal drainage Past Medical History: States he had pneumonia 1 year ago, but has never been hospitalized. Symmetrical anterior and posterior thorax. A physical exam found redness in his throat, an inflamed ear SOAP Note 8_____ NU632_____ Herzing University Name:Scarlin Rhoades_____ Typhon Encounter #: 4316-20240320- 002 _____ Comprehensive:____Focused:__x__ Notices mom if she leaves the room Calms himself down to sleep ALLERGIES none MEDICATIONS Infant Tylenol every four hours as needed SOAP Note for Focused Exam: Cough Name: Danny Rivera Age: 8 SUBJECTIVE DATA Chief Complaint: “I’ve been feeling sick. Patient ID: 35F, otherwise healthy, from home Subjective: The patient is a 35-year-old female who presents with a sore throat for the past 4 days. Subjective. Continue his use of Motrin for fever reduction. ” History of present illness (HPI): Danny is SOAP notes were developed by Dr. United States University. SUBJECTIVE: The patient has had a two-day history of sore throat that is associated with some inspiratory difficulty, especially at night, and chest pain with sneezing and coughing. She has had an ear infection in the past. IDENTIFYING DATA Patient's Initials: JM Informant: Mother and Father Primary Care Provider: CLINICAL HISTORY Chief SOAP Note Template Initials: DR Age: 8 y/o Gender: M Height Weight BP HR RR Temp SPO2 Pain Allergies 4’2” 90 lbs 120/ 76 100 28 37. . 05/06/1987 Male A reliable Log in Join. The patient’s grandmother said that he did have some barking with his cough overnight. S. Advanced Health Assessment 97% (36) 20. SOAP Note Template Leslie Grant / Dr. History of Present Illness (HPI) Chief Complaint (CC) “ I’ve been feeling sick, I’ve been coughing a lot, and I feel Name: Danny Rivera Section: Week 5 - Focused Exam: Cough Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA: Chief Complaint (CC): Reports cough, runny nose, sore throat, and right ear pain. Summarise the salient points: “Productive cough (green sputum)” “Increasing shortness of breath” “Tachypnea (respiratory rate 22) and hypoxia (SpO 2 Episodic SOAP NOTE Subjective Data: Patient Demographics: Initials: JK Age: 7 Gender: Male LMP: N/A CC: "My son has been coughing for the last 2 days" History of Present Illness: An 8 year old boy was brought by his mother to our clinic for a cough that started 2 days ago. Respiratory rate is 16 breaths/minute, unlabored, regular, and inaudible through the nose. Patient plays basketball and needs to have inhaler View danny rivera soap note. No retractions, accessory muscle use, or nasal flaring. Ursula Jackson Date: 06/07/2023 ID: B. OBJECTIVE: VITAL SIGNS: Temperature 97. He had ear infections when young and had pneumonia in the past. University of Texas, El Paso. 9 f 96 Medication: None Food: Click or tap here to enter text. Total views 100+ Kent State N/a soap note sarah condon chief complaint (cc): have sore throat, stuffy nose, and pressure across my forehead and history of present illness (hpi): WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough. He reports that these symptoms have been present for several months and have been getting progressively worse. is a 10 year old male who presents with a 3 day history of sore throat, fever, cough, and ear pressure. 5 cm, which is 24th percentile for age, for a BMI of 16. NURS 622: Advanced Health Assessment. Gradually worsening. Biological mother is informant, pt. 6 kg, which is 57th percentile for age; height 96. Lisa Franks September 12, 2021 2 Subjective Chief soap note sample soap note template subjective information the patient or patient representative told you initials: age: 28 height If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom. This section provides concrete evidence of the patient’s condition and progress. Please follow the soap note, so all areas are coverd. He denies symptoms of cough, coryza, or rhinorrhea. C h e s t P a i n : shortness of breath, leg pain or swelling, palpitations, nausea, diaphoresis, arm pain, cough, fevers. Episodic SOAP Note Template _Rx Peds - Free download as Word Doc (. Reports cough is wet SOAP note documentation subjective chief complaint: 12 year old female with cold symptoms history of present illness: patient has had weeks of cold symptoms. No vomiting, diarrhea, or cough. Denies past or current respiratory illnesses or diseases. The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections. Examples of a SOAP note #2 SUBJECTIVE. “Cough, runny nose, and sore throat x 7 days” HPI: New Asian male patient 28 yo presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Ethnicity: White Gender: Male DOB: 01/01/1972 Insured: Not insured Current. Asthma SOAP Note Template Sample #2. History of Present Illness (HPI): Reports cough started five days ago with coughing every few minutes. docx), PDF File (. Triggers were also discussed that brings on exertional symptoms. old. 1 SOAP Note: Cough. 7-month-old female, no pmhx presents to ED with mother and grandmother from the QHC pediatric clinic with c/o respiratory distress. Submit Search. 8, which is 81st percentile for age. docx - SOAP Note Form S/ Identifying Information Cough, sore throat for 3 days Hx Present Sore throat transcribed medical transcription SOAP note example report for reference by medical transcriptionists and allied health She has a bad cough and stuffy nose. presented to the This is where SOAP note templates prove invaluable. Assignment: SOAP Note #1 – COVID-Due Date: SUBJECTIVE: C/C: 36 y/o F presents c/o nasal congestion, pressure, loss of sense of smell and taste, fatigue, headache, body aches. History of Present Illness: Describes cough as The SOAP note needs to be thorough and completed appropriately for full credit. Apart from the cough, the patient states he has been feeling well and has not had any issues since last being seen by a physician. Name: SUBJECTIVE DATA CC: “I am here for a cough, sore throat, and postnasal drip x 3 days” HPI: Ms. Symptoms began abruptly 3 days ago when he developed a sore throat, pain with swallowing, fever, and headaches. Module. Danny Rivera Pediatric Cough Shadow Health Assessment Documentation Table of Contents: Long SOAP Note Example Short SOAP Note Example SOAP Notes Structure Subjective Objective Assessment Plan Other Info Tips for Writing SOAP Notes Common Abbreviations How do doctors organize all the information about their patients? Back in the 1950s, Lawrence Weed asked himself the same question and came up with a solution — Outpatient FNP Office SOAP Note: Chronic Obstructive Pulmonary Disease (COPD) Patient Initials: P. Denies diarrhea or constipation. She reports a history of childhood asthma but no current treatment. presented with a cough and fatigue lasting 4-5 days. Make sure to wash your hands with soap and water before, during, and after preparing food, before and after eating food, before and after treating a cut or wound, or after contact with someone who is ill. The patient reports a sensation to cough "every few minutes" and View Danny Rivera Cough SOAP Note Due 10:8. The patient has not had a physical in over 5 years and that is why he has been scheduled for a physical. Patient denies cough, chest pain, or shortness of breath. She reports that the cough is Pediatric SOAP note dictation transcribed medical transcription sample report for reference by medical transcriptionists and The patient has had sore throat, dysphagia, and halitosis for about one day. In this blog post, we'll explore 10 SOAP note examples designed to streamline your patient documentation workflow. K. who presents with a barking cough, nasal 12 pts Total Points: 100 I will include the soap note example and also the bates video transcript in written format. The patient is a 2-year-old male who was brought by her mother to the facility due to a running nose, cough, Pediatric Soap Note: Bronchitis. Sample SOAP Note S: V. Occurs every few minutes. Source and Reliability: Self, reliable, Log in Join. HPAM NSG124. On examination, his throat is Episodic SOAP Note and Reflection: Danny Rivera First Name: Danny Last Name: Rivera Gender: Male Age: 8 yrs. Recent upper respiratory infection (URI) resolved 1 week ago. GASTROINTESTINAL: Denies abdominal pain. ” Reports intermittent cough, dysphagia, rhinorrhea, and feeling tired and achy all over. SOAP Note Template: Cough Subjective: Chief Complaint: “I have been coughing for a week and just can’t seem to stop. Immunizations are up-to-date, is currently due for a pneumonia Patient denies cough, chest pain, or shortness of breath. Race: Puerto Rican Source of history: Patient- Danny Rivera and his abuela (grandmother) Subjective Data: Chief Complaint (CC): " I've been feeling sick, I have been coughing a lot and feel kinda tired" History of Present Illness (HPI): Danny Rivera is an 8 Danny Rivera is an 8-year-old male who presents for evaluation of a cough of onset 3 days ago. She says that she sometimes gets a bad cough during Document Pediatric SOAP Note: Cough & Congestion in 4-Month-Old Baby, Subject nursing, from Western Governors University, Length: 9 pages Share and explore free nursing-specific lecture notes, documents, course summaries, and more at NursingHero. Danny Rivera Cough SOAP Note Due 10:8. Danny Rivera, an 8-year old boy, presents with a 5-day cough, fatigue, runny nose, and sore throat. doc / . Subjective SOAP # 2 A SUBJECTIVE. Her sister was just diagnosed with strep and dispensed a course of amoxicillin. Each SOAP note would be associated with one of the problems identified by the primary physician, and so formed only one part of the documentation process. Mother states that she has had a mild cough and congestion for the past 2 days but denies difficult or labored breathing until this morning, N/V/D, difficulty eating or drinking, COVID SOAP Note - Free download as Word Doc (. docx - Download as a PDF or view online for free. What the Patient Tells you. SKIN SUBJECTIVE: The patient is a very pleasant (XX)-year-old gentleman who is coming in for a persistent cough. Return to Assignment (/assignments/432174/) Shadow Health will be performing planned Focused Episodic SOAP Note for Sore Throat. 6, heart rate 106, respiratory rate 30, blood pressure 88/60, weight 15. Here are the specific things that should go into the Objective section of a nurse practitioner SOAP note: PEDIATRIC SOAP NOTE EXAMPLE #1. Patient: LG Age: 20 Sex: Female Race: African American S HPI: A 20-year-old African American female presented to this clinic with a chief complaint stat “ I have had a cough and sore throat for the last three days. EXAMPLE #2: Patient with Productive Cough and Fever: Subjective: Patient M. A 60-year-old female presented with a 4-day history of dry cough, congestion in her chest, hoarseness, and expiratory wheezing. WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough. ” HPI: Cough: X 7 days. Describes cough as This website uses cookies to improve your experience while you navigate through the website. The document presents a SOAP note for a 5-year-old male patient named N. He reports cough with purulent sputum, shortness of breath, and fever for the past three days. Cough soap note Student: Maninderdeep sran United states university FNP592 Common Illnesses across the lifespan Professor: Dr. History of Present Illness (HPI): Patient is a 9-month-old female presenting to urgent care with a persistent dry cough for the past week and SUBJECTIVE: The patient is a (XX)-year-old male who complains of a dry cough with scanty phlegm coming up and chest congestion, headache, nasal DANNY RIVERA COUGH SOAP NOTE 5 ASSESSMENT - Acute bronchitis, otitis media, upper respiratory infection. T. SOAP Note Example NP Pediatric Patient, Example SOAP Note Nurse Practitioners Teen Patient, Nurse Practitioner SOAP Note Example. OBJECTIVE: The patient is ambulatory The SOAP note is formatted with individual sections for recording subjective, objective, assessment, and planning data and information. The patient also complains of generalized weakness and decreased appetite. D. Productive cough with green sputum. Reports fatigue due to cough at night time and not sleeping. I can hardly sleep at night. 23 views. R. This is where SOAP note templates prove invaluable. Age: 65-y Gender: M Ethnicity: Caucasian SUBJECTIVE DATA: Chief complaint (CC): The patient complained of having "fever and a productive cough" for the previous two weeks, as well as "difficulty in breathing on performing any physical activity, such as SOAP Note #1 NU 623:7B Herzing University Name: Samantha Pakkebier Typhon Encounter #:4299-20240129-01 Comprehensive:____Focused:__x__ Endocrine N/A Hematologic/Lymphatic N/A Allergic/Immunologic No active sneezing, wheezing. See the subjective, objective, assessment and plan sections of the sample report. Add supporting photos (optional) O Danny Rivera Documentation Focused Exam Cough Completed Shadow Health. He reports that the cough gets worse at night and is always kept awaken by the cough. NR 602. 2 SUBJECTIVE DATA Biographical and Identifying Data 02/18/2021 at SOAP # 2 A SUBJECTIVE. docx from NURSING MISC at University of the Fraser Valley. SOAP note 3. It is worth a total of 20 points (5 points for each section). Also address personal history of diabetes, hypertension, high cholesterol, and blood clotting disorders, and family history of heart View SOAP Note Template NU623 - Final (1)1015. soap note subjective chief complaint my body hurts for the past history of present illness: ms is 20 year old female who comes to the clinic with cough and. Episodic Visit Your Name: Rachel Dedo Patient Initials: D. Gather further details about the patient’s cough using the SOCRATES acronym. Over the past two weeks, she has noticed Soap Notes - Croup - Free download as Word Doc (. History of Present Illness (HPI): Patient is a 9-month-old female presenting to urgent care with a persistent dry cough for the past week and fever of 101-102 F for the past two days. FOCUS SOAP NOTE 2 SOAP Note Template NU 561 Patient Initials __EC__ Subjective Data: Chief Complaint: patient states "I have a sore throat, nasal congestion, body aches, headache, cough with greenish-yellow phlegm, and sinus pressure for 3 days" History of Present Illness: EC is a 20-year-old female presenting with the onset of symptoms including ALLERGIES: No known drug allergies. D Date: 12/14/2023 Time: 12:35 pm Ethnicity: White (Caucasian) Age: 32 years Sex: F SUBJECTIVE CC: “Coughing which recently became productive of sputum. No nausea or vomiting. PROBLEM LIST-Cough, SOAP Note for Focused Exam: Cough Name: Danny Rivera Age: 8 SUBJECTIVE DATA Chief Complaint: “I’ve been feeling sick. docx from NURS MISC at Kent State University. Also, he has a habit of stopping his medications when he feels well. Anteroposterior-transverse ratio is 1:2.