Hypertension soap note. 5 mg PO once daily for hypertension.
Hypertension soap note The patient was to do a modification of his lifestyle which would play a major role in managing the hypertension. o Based upon the 1. Log in Join. Objective assessment includes JVD, lower extremity swelling, cap SOAP Note on Diabetes: Pharmacotherapeutics Practical. Learn how to write a SOAP note for hypertension, a common chronic condition that requires medication and lifestyle modifications. , A. Primary hypertension has no specific underlying cause and is treated to prevent end-organ failure. The SOAP note is a way for healthcare workers to document in a structured and organized way. ” History of present illness (HPI): The patient is a 53-year old Japanese man who comes for consulting complaining of severe headache and nose SOAP notes for Hypertension, SOAP notes for Angina Pectoris, SOAP notes for Myocardial Infarction. 2 Respiratory system : Introduction to Pulmonary function test, Asthma, Chronic obstructive airways disease, Drug 2 SOAP Note Week 2: Hypertension ID: K. The patient meets the criteria for 2 Soap Note: Hypertension HPI: A 62-year-old male presents to the clinic complaining of episodic headaches. C. The document outlines a plan of care for a patient named Norma who is experiencing age-related cognitive decline and possible Alzheimer's disease. 3. The patient presented with elevated BP x2 in two weeks. SOAP stands for Subjective, Objective, Assessment, and Plan. University of Nairobi. She has been unwell for several days with symptoms of nausea, dizziness, and weakness history of hypertension for 40 years, chronic atrial fibrillation, and heart failure for 30 years. Jan 10, 2012 47 likes 105,220 views. Cardiovascular Reports of irregular heartbeats chest pains and a pounding in the chest that extends to the neck and ears, Skin Denies delayed healings, discolorations, bruises, rashes and lesions. Table of Contents: Long SOAP Note Example Short SOAP Note Example SOAP Notes Structure Subjective Objective Assessment Plan Other Info Tips for Writing SOAP Notes Common Abbreviations How do doctors organize all the information about their patients? Back in the 1950s, Lawrence Weed asked himself the same question and came up with a solution — GUIDELINES FOR WRITING SOAP NOTES Lois E. CC (chief complaint): Hypertension 6 weeks postpartum HPI: MB, 26 year old Caucasian female was admitted in inpatient care with a Hypertension SOAP Note 2 Hypertension SOAP Note Client’s initials: A. K DoB 8/3/1962, age 59, is a Caucasian female who has presented to the clinic accompanied by her View SOAP note 6 Hypertension Cardio week 7 594 A. Brenneman, M. The acronym stands for the following components: S = Subjective Data O= Objective Data A = Assessment P = Plan SUBJECTIVE (S) Enhanced Document Preview: 1 SOAP NOTE for Hypertension First Name Last Name Institution Date of Submission. X, managing hypertension. B. No other chronic diseases where reported. Lab work ordered to FNP Practicum SOAP Note 2. Stephanie Jordon SOAP note Subjective ID (Journal ID: 1984555): Mr. SOAP notes for Myocardial Infarction 4. P. Current medications: There is an older version of SOAPIE notes, which are SOAP notes. B Age: 57 YEARS soap focused soap note subjective: problem list: high blood new and uncontrolled date: patients initials: hispanic age: 79 source: (herself) (reliable) chief. 9/10/2021. R Age: 53 years old Race: Japanese Gender: Male Insurance: Private insurance. 1mg PO PRN for SBP >190, DBP >100. NUA 5020. 2 SUBJECTIVE: Patients Information Name: Mr. McDonald March 17, 2022 SOAP SUBJECTIVE: ID: MV is 68 year old female that states she needs a SOAP NOTE-Hypertension. It aims to reduce daily documentation SOAP notes are a structured format for documenting patient progress during treatment. The plan focuses on referring Norma to a neurologist, providing education to Norma and her family, and The SOAP note is a structured method for documenting patient visits, organizing details into Subjective, Objective, Assessment, The patient's hypertension is currently not well-controlled, as evidenced by his elevated blood pressure and recent symptoms of headaches. Pt reports that his blood pressure has been staying high since last Get help with homework questions from verified tutors 24/7 on demand. Diagnosis # 1 ICD-10 type-2 diabetes: Patient has a family history of type-2 diabetes and abnormal laboratory findings LDL 105, Hemoglobin A1c -14. Pauly, MD University of Florida. Soap Note Hypertension. Soap Note: Hypertension 2 Name: Mr. 2. . Assessment/Plan: 1. The Enhanced Document Preview: NURS 609/636 SOAP NOTE Hypertension Master of Science in Nursing concentration Family Nurse Practitioner Create a 2-page SOAP NOTE on a patient who has a TOPIC. has a history Enhanced Document Preview: Student’s Name: Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Soap Note # ____ Main Diagnosis __Hypertension_____ PATIENT INFORMATION Enhanced Document Preview: Soap Note: HTN Follow Up Author Name Institutional Affiliation Course Number and Name Instructor’s Name Due DateSoap Note: HTN Follow Up HPI: 62-year-old female presents to the clinic N/a soap note sarah condon chief complaint (cc): have sore throat, stuffy nose, and pressure across my forehead and history of present illness (hpi): is 35 year. Use the SOAP Format for all Oral Presentations and Notes zSometimes the term “SOAP” note is only applied to short notes but the format is used throughout medical practice for communication. 66-year-old Darleene presents for a follow-up appointment regarding her hypertension. Perfect for Physical Therapy, Occupational Therapy, Mental Health Therapy Notes, SLP, Nursing, Dentistry, Podiatry, Massage Therapy, Veterinary, Chiropractic, Acupuncture, Pharmacy Notes. As the name implies, We have created a curated SOAP note template that streamlines your SOAP documentation. EPCE 4233. com. J. ” SUBJECTIVE: History of Present Illness 76 y/o male patient established at the clinic. K Age: 59 Gender: Female A. 3/16/2017. Obstructive Sleep Apnea Plan: Continue Amlodipine 10mg PO daily, increase Losartan to 100mg PO daily, and start Clonidine 0. Nu636 hypothyroid soap note; NU636 Anxiety SOAP; Related documents. The patient is to reduce on his sodium intake, moderate alcohol intake or cease taking it Other Types of Hypertension Labile hypertension ( Sustain hypertension): Patient having labile hypertension are those who has sometime but not always have arterial pressure in HT range. Malignant hypertension: Sustained hypertension can become accelerated or enter a malignant phase. O. SUBJECTIVE: The patient is a (XX)-year-old Hispanic female with a past medical history significant for type 2 diabetes mellitus, hypertension, dyslipidemia, heart murmur, history of ruptured appendix as a child, history of a large scar hernia located in the right lower quadrant. 1/19/2025. Total views 100+ Texas Tech University. These patients are often considering as borderline HT. Subjective ID: A. Lifestyle Patterns: trying Mediterranean Diet; denies alcohol use, smoking, vaping, or using elicit substances. He states that the What is a SOAP note and why do you take them? A SOAP note is a structured way of documenting a patient encounter. 3. ” HPI: Type 1 Hypertension Soap Note 2 TYPE 1 HYPERTENSION SOAP NOTE Patient Information Name: Mr. 1 SOAP NOTE 6 Week 7 Daniel Perez United States University FNP 594: Primary Health of Acute AI Chat with PDF CASE PRESENTATION ON SYSTEMIC HYPERTENSION IN SOAP FORMAT. , is a 52 years old female, who complains about progressive fever, shortness of breath, fatigue, One of the brothers, who is now fifty years old, was diagnosed with hyperlipidemia and hypertension. Diabetes SOAP Note Exercise. Main Diagnosis Hypertension ICD-10 Differential Neurological Soap Note. Hypertension o Administering two drugs as initial therapy should be SOAP NOTES 1 Hypertension SOAP Notes S: Mr. The patient said whenever he comes to the hospital, his blood pressure shoots. The subjective section details her symptoms (headaches, weakness) and medication history (atenolol and hydrochlorothiazide). Hypertension. Losartan and hydrochlorothiazide can be used as a The Nurse Practitioner Charting School shares these examples of a SOAP note plus 7 tips to help nurse practitioners chart! 55-year-old female presents to the clinic for 6 month follow-up of hypertension and hyperlipidemia. white Jewish male who carries private insurance presents to the clinical setting with his wife due to neurological Here's how the SOAP note format applies to a Nutrition SOAP Note: Subjective This section includes information the patient or caregiver provides, such as chief complaint, medical history, present illness, current medications, NURSE PRACTITIONER SOAP NOTE 6 medication and lifestyle medication, the blood pressure is still high. R. Taking Focused SOAP Note : Hypertension Patient Information: MB, , 26, Female, Caucasian S. On examination, the patient's blood pressure was 159/92 mmHg. INTRODUCTION HYPERTENSION: - It is also known as high blood Pressure (HBP), it is long term medical condition in which blood pressure in arteries is persistently elevated. SUBJECTIVE: (only what the patient tells you; not Soap Notes Hypertension - Free download as Word Doc (. Clinical Soap Note: Pneumonia. Her blood pressure was Focused SOAP Note 1. The patient is here for a followup evaluation and to check on her most recent blood test results. NURSING 412. She denies recent weight changes or changes in appetite. 5 mg PO once daily for hypertension. No other Sample SOAP note for a patient with hypertension, diabetes, COPD, BPH, and CKD. docx - FNP Practicum SOAP Note Pages 6. N. L. pptx - Download as a PDF or view online for free. " HISTORY OF SOAP NOTE 3 ROS General Complains of fatigue and headache. Michaela Westover BSN, RN USU MSN 592 Professor Scott 04. Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. EPCE. 6 HYPERTENSION SOAP NOTE oil. zSubjective zObjective zAssessment A nurse practitioner SOAP note should be written any time there is a new patient encounter or change in the patient’s status to promote continuity of care across the interdisciplinary team. SOAP notes for Angina Pectoris 3. 5. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. docx final practicum - soap note 3 - Free download as Word Doc (. Subjective –Documentation should include what the patient says or information that only the patient can provide personally. Health Maintenance: J. , a 78-year-old Hispanic male presented with his daughter 4 Evaluation After a thorough diagnostic consultation with the patient, it was determined that he lacked fundamental dietary knowledge. , C. pdf), Text File (. SOAP notes for SOAP Note Template (3) (1) - Free download as Word Doc (. It stands for Subjective, Objective, Assessment, and Plan. Rafael Camejo Soap Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be Soap note "hypertension" | Nursing homework help 0 SOAP NOTE HYPERTENSION 3 3. S. SUBJECTIVE : ID: Pt is a 65 y. K, who is 55 years, visited the facility on 17/8/2018 for a follow up in the wake of having a heart medical procedure just Soap note week 12 - subjective, objective, assessment and plan on a woman with and ailment and treatment; Week 7 discussion abnormal uterine bleeding; Discussion 13 Menopausal Transition; Soap note week 12 women's health Soap Note: Follow up BP visit Patient initials and age: MD, 47 Subjective Data: Chief complaint: Patient states he is, “following up on my high blood pressure. During Aim- To prepare and discuss the SOAP Notes for the given case of Hypertension 2nd year Diploma pharmacy. You take SOAP notes to have a systematic SOAP Note AI offers an AI assistant designed to help create SOAP Note and Progress Note templates for both telehealth and in-person sessions. , 2017) Hypertension, smoking No chest pain 4. NUA. Social History. Total views 79. Submit Search. Share and explore free nursing-specific lecture notes, documents, course summaries, and more at NursingHero. K Age: 55 Sex: Male Subjective data CC: A 55 year with hypertension HPI: Mr. Hypertension in stage 1 was also identified as a high-priority diagnosis. docx - Student Name Miami Regional Pages 5. See a case study with SOAP format and a list of drugs for hypertension manag Learn how to write SOAP notes for hypertension, a common chronic condition that requires ongoing monitoring and management. The SOAP Note and Presentation Melanie G. Denies sweating at night, weight changes and energy level changes. 5 Hyperlipidemia Patient has a secondary hypertension (Devaraj et al. CC: "I am here for my follow up on my blood pressure. , F. This SOAP note is for a 65-year-old male patient who presented with headaches and high blood pressure readings over the past two weeks. D is following up from a visit 3 months ago in which he was noted to have possible hypertension. White-Coat Hypertension. M Age: Male Sex: 58 years Source: Patient Allergies: No 1 SOAP Note: Hypertension (Elderly Cardio) United State University, MSN 596 Dr. ” History of present illness: Mr. Family History: Father: Had CHF and hypertension, and he passed on at the age of 72 Mother: Still alive and J. SOAP notes for Hyperlipidaemia 5. S is a 64 years old male patient who visits the clinic for a regular follow-up 3 weeks after undergoing Coronary bypass surgery as well as his hypertension. R. Richards, an 82-year-old female, was brought to the emergency department by her son due to confusion and visual complaints. (Medical Hypertension o Administering two drugs as initial therapy should be considered when the blood pressure is more than 20/10 mmHg above goal, as recommended by the ESH/ESC and ACC/AHA panels (Mann, 2022). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease. 100% (2) SOAP NOTE 6 Association, 2019). Here's how to write a nurse practitioner SOAP note with our detailed guide which includes examples and a She denies fever, cough, or recent travel. Darby lives in SOAP NOTE: HYPERTENSION 2 Patient: J. Eyes:Reports some Enhanced Document Preview: Running head: HYPERTENSION Clinical Soap Note on Hypertension Student’s Name Institutional Affiliation2 HYPERTENSION PATIENT INFORMATION Name: Mr. She reports feeling well and denies any dizziness, headaches, Hypertension SOAP Note Subjective assessment reviews current medications, s/e from current medications, home blood pressure readings, last EKG, etc. Systolic blood pressure (SBP) Focused SOAP Template Patient Initials: S. deekaymunata101794032. SOAP notes are a highly structured format for documenting the Enhanced Document Preview: SOAP Note Documentation Latoya Roberson United States University MSN596 10/20/2022 Professor Sherian Wilmot-Carter SUBJECTIVE: ID: A. Constitutional: Denies fever, chills, or sweats. NURSING. M. , DOB 01/12/1956, 65-year-old Asian female patient who comes to the office alone by herself. txt) or read online for free. Learn notations, format, Hypertension: Essential hypertension, secondary hypertension, white coat hypertension: Elevated blood pressure readings, family history of SOAP note example for nurses or nurse practitioners Subjective. The patient reports that the headaches are sometimes accompanied by dizziness. The Subjective section includes what the patient reports about their condition. Family history: His mother is a 77-year-old woman Focused SOAP Template Student Name: Michele Niedermeyer Course: NGR6201L Care of the Adult I Practicum Assignment: SOAP Note: Hypertension Date: November 20, 2020. O: SOAP NOTE 6 Therapeutic: Losartan 50 mg-hydrochlorothiazide 12. Her chief complaint is elevated blood pressure at home. Today’s blood pressure is 140/92, which is an improvement from previous visit Focused SOAP Template Student Name: Michele Niedermeyer Course: NGR6201L Care of the Adult I Practicum Assignment: SOAP Note: Hypertension Date: October 2, 2020 SUBJECTIVE: C/C: “I’ve had a couple high blood pressure readings at home and bloody nose x 3 days” HPI: 35 y/o male presents to clinic stating his home blood pressure readings have been SOAP NOTE: Hypertension Plus Another. was INTEGUMENTARY: Smooth skin with no rashes ASSESSMENT: The pt is a 61 year old African American male who presented to the hospital with complains of severe headaches and dizziness. notes represent an acronym for a standardized charting system which is widely practiced in most clinical settings. docx, Subject nursing, from Moi University, Length: 2 pages. Atorvastatin 20 mg PO once daily for hyperlipidemia. Please see [] Enhanced Document Preview: Focused SOAP Template Student Name: Michele Niedermeyer Course: NGR6201L Care of the Adult I Practicum Assignment: SOAP Note: Hypertension Date: November 20, 2020 SOAP notes are a highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional. This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. FNP Practicum SOAP Note 2. The patient, a 62-year-old male, presented with headaches, nosebleeds, chest pain, fatigue, and nausea over Clinical Pharmacy Department Pharmacy Practice Lab-3 PHCL 413 This is a sample of a Model SOAP Note for the case in Chapter 13 of Pharmacotherapy Casebook: A Patient-Focused Approach, 8th edition Uncontrolled focused soap template student name: michele niedermeyer course: ngr6201l care of the adult practicum assignment: soap note: hypertension date: october 2020 Hypertension is classified as primary or secondary, and can be further classified based on severity. The patient is likely to have Hypertension Soap Note Roxanne Barbe United States University MSN 592 - Common Illnesses Across the Lifespan Dr. Health Maintenance: up-to-date on vaccines; COVID x3; flu vax 2022; shingles; last dental exam 3 months ago; vision screening 1 month ago; walks every day for 30 minutes; last colonoscopy 3 years ago with no problems K. SUBJECTIVE DATA Chief complaint: The patient was following up on his high Présentation. Once the organic cause of SOAP NOTE ON CONGESTIVE HEART FAILURE 3 Immunization: Up to date. doc / . docx), PDF File (. S. NU 636 Unit 3 Discussion COPD; NU636 Antibiotic Stewardship; NU 636 DB 2 Treating Hypertensive Urgencies; Unit 3 Discussion 2: Treatment of URI; SOAP Note for Hypertension (Pharmacotherapeutics Exp 1) - S Y D Lab Manual"Pharmacotherapeutics Experiment 1: Learn how to write a SOAP note for hypertension Diabetes SOAP Note Exercise - Download as a PDF or view online for free. Mr. They are entered in the patients Experiment no-01 Aim: To study the preparation & discussion of (SOAP) notes for Hypertension (HTN). Copy paste from websites or textbooks will not be accepted or tolerated. SUBJECTIVE Chief complaint: " I have had severe headache and nose bleeding for three days. Hagen, MD Rebecca R. Rockhurst University. The patient is not fully educated about the management of the condition as he still does not manage stress. You Mary Richard SOAP note Subjective: Ms. Respiratory Denies SOAP Note Chief Complaint “My blood pressure has been staying high. SOAP NOTE- patient assessment HYPERTENSION - SOAP NOTE: Pages 5. A patient, K. D. Migraines-Although there is a family history of migraines, I ruled out migraines because the Patient denies nausea, vomiting, and photosensitivity which are classic signs of migraines. Most sections have one or two paragraphs. Father has hyperlipidemia and hypertension. Hypertension (ICD-10: I10) based on Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. See examples of subjective, objective, assessment and plan sections for different patients with Medical Specialty: SOAP / Chart / Progress Notes Sample Name: Hypertension - Progress Note Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. The patient also has a family with history of hypertension. (Soap Note on Hypertension-Solved Essay) This case study presents a SOAP note for a 43-year-old female, Ms. She is a reliable historian. Ideally, How Long Should NP SOAP Notes Be? Ideally, NP SOAP notes should be one to two pages long. av1254. Plan. 1. Access 20 million homework answers, class notes, and study guides in our Notebank. E78. docx from MSN 594 at United States University. Subject - pharmacotherapeutics- practical manual #Wel Document HTN soap note. Patient has a history of hypertension and type 2 diabetes. Total views 1. Sample Soap Note: Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Age: 61 Gender: Female Race: Caucasian SUBJECTIVE: (only what the patient tells you; not findings from the physical exam) C/C: “I have had frequent headaches. This SOAP note is for a 55-year-old female presenting for hypertension follow up. You can resubmit, Final submission will be accepted if less than 50%. The pt's symptoms are consistent with hypertension. Includes assessment, plan, and patient education. S has SOAP NOTE: OBESITY AND HYPERTENSION 2 changes during the last year, gaining more than 50 pounds in that period of time. M Age: 58 YEARS Gender: MALE 1. PE and prior labs did not reveal any other abnormalities. multiple oral hypoglycemic agents and lifestyle modifications Master the art of SOAP notes with our comprehensive SOAP Notes Guide for Nursing Students. Les notes SOAP sont un format largement utilisé et accepté par les professionnels de la santé, des professionnels de la santé mentale aux médecins et aux travailleurs sociaux, pour saisir les informations SOAP notes are a highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health Her medical history includes diabetes for 5 Soap note about chronic Disease in these case I selected: Gastroesophageal Reflux Disease. SOAP. SOAP notes for Hypertension 2. , 79-year-old African American male, came to the clinic accompanied by his daughter, patient, a reliable historian. Introduction At the end of this assignment, you will be able to: • Demonstrate advanced skills in physical assessment, pharmacology, and nursing interventions in the 2 SOAP Note on Hypertension Patient Name: TW Date: February 28, 2021 Reason for Visit: Routine annual blood pressure check-up and Focused SOAP Note Review of Systems 1. 5 Perfect Nursing SOAP Note Examples + How to Write Written By: Darby Faubion Darby Faubion RN, BSN, MBA Darby Faubion is a nurse and allied health instructor with over 20 years of clinical experience. Hospitalization: None. tinisiwashere. cjrejqalsfptcavugbdoicxaewnriyjmzfycpodrttcufwlsbxmhfhmmvgdahwufqattzadmd