SOAP Nursing Note

Complete Note
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Subjective:
[textarea cols=80 rows=1 default="one or more symptoms in patient's words, duration..."]
History of Present Illness:
[textarea cols=80 rows=5 default="PQRST - Provocative or Palliative maneuvers, symptom Quality, the Region involved, the Severity and Temporal pattern of symptom..."]

Objective:
Physical Examination
[textarea cols=80 rows=2 default="VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level"]
[textarea cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."]
[textarea cols=80 rows=1 default="RESPIRATORY: no cough/sputum/SOB/chest pain. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
[textarea cols=80 rows=1 default="GENITOURINARY: no dysuria/frequency/blood in urine/incontinence"]
[textarea cols=80 rows=1 default="GASTROINTESTINAL: no constipation/diarrhea/blood in stool/melena.Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[textarea cols=80 rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions, no rashes, bruising, nail or hair changes."]
[textarea cols=80 rows=2 default="NEUROLOGICAL: CN II-XII intact. No weakness, headache, or other painStrength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."][textarea cols=80 rows=3 default="PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal."]

Medications:
[textarea cols=80 rows=5 default="medication name/dose/indication/duration"]

Assessment:
[textarea cols=80 rows=1 default="medical Dx"]

Plan:
[textarea cols=80 rows=2 default="#1 Problem"]
[textarea cols=80 rows=2 default="#2 Problem"]
[textarea cols=80 rows=2 default="#3 Problem"]
[textarea cols=80 rows=2 default="#4+ Problem"]

Narrative:
[textarea cols=80 rows=5 default="summary of visit"]
Subjective:

History of Present Illness:


Objective:
Physical Examination










Medications:


Assessment:


Plan:





Narrative:
Result - Copy and paste this output:

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