New Admit

Vital signs: T [text size="4"] F, HR [text size="4"] bpm, RR [text size="4"], BP [text size="7"], SpO2 [text size="2"]% [select value="RA|2LNC|"]
Resident is admitted to facility with diagnoses: [text size="50"]. Medication adherence has been [checkbox value="Good|Fair|Poor|Questionable|Not taking medications as prescribed|Taking more than prescribed"] [text size="50"]. [checkbox value="Allergies include |No known allergies"][text size="50"].  Resident is [checkbox value="Calm and cooperative|Irritable|Oppositional|Oriented and ambulatory|Disorganized|Responding to internal stimuli|Required significant support following direction|Sedated|Unsteady on feet|Unable to participate in admission process"].[checkbox value="Fall precautions initiated|Staff notified of contact precautions|Message left with infection control| Plan to monitor patient for safety, encourage patient to accept scheduled medications"]. Resident is [select value="awake and alert|sleeping|"] [checkbox value="oriented x|with forgetfulness|confused|no c/o pain|c/o pain (include assessment)|regular respiration even and unlabored, lungs clear to auscultation, no coughing, denies SOB or chest pain|heart sounds regular rate and rhythm|bowel sounds normoactive all quadrants, abdomen soft and nontender, Last BM ( _ )|continent of bladder, voids clear yellow urine, denies voiding difficulties, denies frequency or urgency, no flank pain|moves extremities without difficulties"] [checkbox value="Plan to "][checkbox value="Maintain contact precautions|Maintain fall precautions|adjusting well to roommate, staff, environment|call light within reach|kept clean and comfortable|"].
Vital signs: T F, HR bpm, RR , BP , SpO2 %
Resident is admitted to facility with diagnoses: . Medication adherence has been . . Resident is . . Resident is .

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.53, 17 form elements, 24 boilerplate words, 8 text boxes, 7 checkboxes, 2 drop downs, 49 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: