MN552 U4 assignment: Comprehensive SOAP Note

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1.     
Biographical Data

a.      
L.P.

b.     
123 Main street

c.      
786-299-XXXX

d.     
English

e.      
Self

f.       
30- DOB 05/02/1988

g.     
Miami, FL

h.     
Female

i.       
White

j.       
Single

k.     
Hispanic

l.       
Associates degree in Nursing

m.   
RN

n.     
Health Insurance- Florida Blue

 

2.     
Chief Complaint:

a.      
“I hurts when I urinate”

b.     
Includes when the problem started- “3 days ago”

3.     
 History of Present Illness:

P – Provocative or palliative (“It hurts when I urinate”

Q – Quality or quantity (Urine is yellow, “I have to urinate frequently”)

R – Region or radiation (Pelvic region).

S – Severity (8 from scale of 0-10).

T – Timing (Started happening 3 days ago)

U – Understand Patient’s Perception of the problem (What do you think it means?)

 

4.     
 Past Medical History

a.      
Medical Hx: Patient denies

b.     
Childhood Illnesses: Patient denies

c.      
Obstetric HX: Number of pregnancies -0, term deliveries- 0, preterm births-0, abortions-0, number of children living-0

d.     
Immunizations: up to date

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