Transcription of Running head: SOAP NOTE ONE Patient Encounter SOAP …
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Running head: SOAP NOTE ONE Patient Encounter SOAP …
Running head: soap note ONE. Patient Encounter soap note #1. M. Michelle Piper, MSN, RN. Submitted in Partial Fulfillment of the Requirements for GNRS 5568 Older Adult Chronic Illness The University of Texas Medical Branch School of Nursing Fall 2013. 2. soap note ONE. SUBJECTIVE. Ms. KH is a 47-year-old Caucasian female who presented to the Magnolia Healthcare clinic October 11, 2013 alone to review abnormal lab work. History of Present Illness & Analysis of Symptom Pt reports that she had labwork drawn one week ago as part of her six-month follow-up appointment. She reports feeling well and healthy today. She states that she thinks her cholesterol labs were probably high.
Robaxin 750 mg PO at bedtime as needed for migraine pain Sumatriptan 6 mg SC injection as needed for migraine Restoril 30 mg PO at bedtime as needed for insomnia All immunizations UTD. Pt reports no EtOH, no recreational drugs, (+) smoking (1 pack/day x 25 …
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