Progress Note - SOAP Format

Date:
Room number:
Pt name:
Code status:

SUBJECTIVE:
Pt feels better today, calmer, no CP or SOB, no N/V, NPO for cath. at 11: 30
AM.

OBJECTIVE:
Vital Signs:
36.2-74-18-129/42
SpO2 95% on 3 L

I=
O=

LABS:

N= B= L=

HEENT: NC/AT
LUNGS: CTA (B)
HEART: Clear S1S2, RRR
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: no edema

ASSESSMENT:
-CAD - stable angina S/P PTCA 10 yrs ago-> positive persantine stress test
3/10/05-> cath. today
Cardiac CRP increased
-HTN

PLAN:
-H/H at 8 PM
-I/O
-CBCD, BMP in AM

Consults:

MEDICATIONS:
Nitro patch
Flagyl + Cefazolin

Signature:


Created: 2/2005
Updated: 03/08/2007

3 comments:

  1. Anonymous2/26/2010 1:44 PM

    how you use the figure (lines ) under labs

    ReplyDelete
  2. tai3/18/2011 7:55 AM

    CBC is >----< in the > is wbc, above the line is hbg, below the line is hct, and in the < is plt

    CMP is ----l----l----< with the first box above the line is Na, the second one is cl, and the third is BUN. On the bottom of the line the first one is K, the second is CO2, and the third is creatinine. In the < is glucose.

    ReplyDelete
  3. tai3/18/2011 7:56 AM

    I think what you are looking for is on the 4th page of this attachment

    http://cpmcnet.columbia.edu/dept/ps/...Guide/SOAP.doc

    ReplyDelete