What This Document Is
This document is a completed Week One Subjective portion of a SOAP note, a standardized format healthcare providers use to document patient encounters. It represents an initial assessment of a 28-year-old female patient presenting with a foot wound and a history of asthma and type 2 diabetes. The note demonstrates how a provider would record a patient’s reported symptoms, medical history, and current medications.
Why This Document Matters
This example is crucial for students in Advanced Physical Assessment courses (like Chamberlain University’s NR 509). It serves as a practical illustration of translating patient information into a structured medical record. It’s most valuable when students are learning to conduct patient interviews, document chief complaints, and accurately record relevant medical history. This type of note is used in all clinical settings to ensure comprehensive and consistent patient care.
Common Limitations or Challenges
This document *only* provides the Subjective portion of a complete SOAP note. It does not include the Objective (physical exam findings), Assessment (diagnosis), or Plan (treatment strategy) sections. It’s a starting point for understanding documentation, not a substitute for comprehensive clinical training or a complete patient case study. It also doesn’t cover variations in SOAP note formatting across different healthcare systems.
What This Document Provides
The full document includes:
* A completed Subjective section with patient initials (TJ), age, gender, and vital signs.
* Detailed documentation of the patient’s chief complaint regarding a foot wound, including onset, location, duration, characteristics, aggravating/relieving factors, and current treatment.
* A comprehensive medical history, including pre-existing conditions (type 2 diabetes, asthma), medication list (Tramadol, Albuterol, Neosporin, Ibuprofen), allergies (Penicillin, cat dander/dust), and relevant social history.
* Information regarding past hospitalizations, immunizations, and lifestyle factors.
* Details regarding the patient’s reasons for discontinuing Metformin.
This preview *does not* include the Objective, Assessment, or Plan sections of the SOAP note, nor does it offer detailed explanations of medical terminology or assessment techniques.
