Nursing note for adult patient 39 yr old-sickle cell disease
CONPH NSG6340/NSG6440 Subjective, Objective, Assessment, Plan (SOAP) Notes
102023
Student Name:
Course:
Patient Name: (Initials ONLY)
Date:
Time:
Ethnicity:
Age:
Sex:
SUBJECTIVE (must complete this section)
CC:
HPI:
Medications:
Previous Medical History: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries:Surgeries:
FAMILY HISTORY (must complete this section)
M:
MGM:
MGF:
F:
PGM:
PGF:
Social History:
REVIEW OF SYSTEMS (must complete this section)
A Practicing RN-BSN
General:
Cardiovascular:
Skin:
Respiratory:
Eyes:
Gastrointestinal:
Ears:
Genitourinary/Gynecological:
Nose/Mouth/Throat:
Musculoskeletal:
Breast:
Neurological:
Heme/Lymph/Endo:
Psychiatric:
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight:
Height:
BMI:
BP:
Temp:
Pulse:
Resp:
General Appearance:
Skin:
HEENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Breast:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Lab Tests:
Special Tests:
DIAGNOSIS (Minimum required differential and presumptive Dx’s, can do more)
Differential Diagnoses
•Diagnosis, (ICD 10 code and reference):•Diagnosis, (ICD 10 code and reference:)•Diagnosis, (ICD 10 code and reference:)reference):•Diagnosis, (ICD 10 code andreference):
Diagnosis
•Presumptive diagnosis (ICD 10 code and reference):
Plan/Therapeutics:
Diagnostics:
Education Provided:
