Week 6 Soap Notes
SOAP Note
Create three SOAP notes using correct medical terminology from the patient information in Appendix C.
• Organize the information correctly
• Format the SOAP notes
• Revise language where necessary
Post your paper as a Microsoft® Word attachment.
Patient One – Chapter 6
Soap Notes
Date: Sat, Aug 27, 2011 04:05 pm Chart #: 1234-567-1234 Age: 22
Name: Susan Smith Date of Birth: 03/11/89 Sex
: F
S: Patient says she has been having acute back discomfort over the past 5 days and frequent headaches.
Has been advised that she has got sickle cell anemia.
Affected person isn't on any medicine.
Affected person says she has not been eating food much.
CC: Acute back discomfort and frequent headaches.
Background of Current Condition: Back discomfort and headaches
Previous Health Background: Sickle Cell Anemia
O: Skin: Shade is typical
HEENT: Usual
Affected person is cautious.
Doctor realizes that the affected person has ache in abdomen above lumbar spinal cord
Affected person is informed that she is likely to get blood and provide her IV with liquids.
IV will also include medication for ache.
Vital Signs: BP: 140/60 PR: 38 RR: 22 T: 99°F W: 150lbs
A: Blood function results:
WBC: 4300,
HGB: 13.1 g/dl
HT: 39.9%
PLTS: 162,00
SEGS: 65.9
LYMPHS; 27
Monos: 3.4
Frequent headaches and acute back pain because of sickle cell crisis.
Dx: Sickle cell Crisis
P: Doctor admits affected person in hospital immediately.
Doctor will come back in the morning hours to see affected person once again.
Patient Two – Chapter 7
Soap Notes
Date: Mon, Aug 22,2011 Chart #: 123-456-789 Age: 26
Name: Mike Jones Date of Birth: 02/02/1984 Sex: M
S: HEENT: Normal
Neck: Supple, not any swelling
Breathing: No problem
Extremities: Not any swelling
Stomach : Not any problem
Blood sugar :200mg/dl
Affected person says he noticed abscess on his buttock and is having ache.
He had been observed in the ER and a cut was
Create three SOAP notes using correct medical terminology from the patient information in Appendix C.
• Organize the information correctly
• Format the SOAP notes
• Revise language where necessary
Post your paper as a Microsoft® Word attachment.
Patient One – Chapter 6
Soap Notes
Date: Sat, Aug 27, 2011 04:05 pm Chart #: 1234-567-1234 Age: 22
Name: Susan Smith Date of Birth: 03/11/89 Sex
: F
S: Patient says she has been having acute back discomfort over the past 5 days and frequent headaches.
Has been advised that she has got sickle cell anemia.
Affected person isn't on any medicine.
Affected person says she has not been eating food much.
CC: Acute back discomfort and frequent headaches.
Background of Current Condition: Back discomfort and headaches
Previous Health Background: Sickle Cell Anemia
O: Skin: Shade is typical
HEENT: Usual
Affected person is cautious.
Doctor realizes that the affected person has ache in abdomen above lumbar spinal cord
Affected person is informed that she is likely to get blood and provide her IV with liquids.
IV will also include medication for ache.
Vital Signs: BP: 140/60 PR: 38 RR: 22 T: 99°F W: 150lbs
A: Blood function results:
WBC: 4300,
HGB: 13.1 g/dl
HT: 39.9%
PLTS: 162,00
SEGS: 65.9
LYMPHS; 27
Monos: 3.4
Frequent headaches and acute back pain because of sickle cell crisis.
Dx: Sickle cell Crisis
P: Doctor admits affected person in hospital immediately.
Doctor will come back in the morning hours to see affected person once again.
Patient Two – Chapter 7
Soap Notes
Date: Mon, Aug 22,2011 Chart #: 123-456-789 Age: 26
Name: Mike Jones Date of Birth: 02/02/1984 Sex: M
S: HEENT: Normal
Neck: Supple, not any swelling
Breathing: No problem
Extremities: Not any swelling
Stomach : Not any problem
Blood sugar :200mg/dl
Affected person says he noticed abscess on his buttock and is having ache.
He had been observed in the ER and a cut was