MN552 U4 assignment: Comprehensive SOAP Note
02/08/2019/Interview:
1.
Biographical Data
a.
L.P.
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b.
123 Main street
c.
786-299-XXXX
d.
English
e.
Self
f.
30- DOB 05/02/1988
g.
Miami, FL
h.
Female
i.
White
j.
Single
k.
Hispanic
l.
Associates degree in Nursing
m.
RN
n.
Health Insurance- Florida Blue
2.
Chief Complaint:
a.
“I hurts when I urinate”
b.
Includes when the problem started- “3 days ago”
3.
History of Present Illness:
P – Provocative or palliative (“It hurts when I urinate”
Q – Quality or quantity (Urine is yellow, “I have to urinate frequently”)
R – Region or radiation (Pelvic region).
S – Severity (8 from scale of 0-10).
T – Timing (Started happening 3 days ago)
U – Understand Patient’s Perception of the problem (What do you think it means?)
4.
Past Medical History
a.
Medical Hx: Patient denies
b.
Childhood Illnesses: Patient denies
c.
Obstetric HX: Number of pregnancies -0, term deliveries- 0, preterm births-0, abortions-0, number of children living-0
d.
Immunizations: up to date
