Resurrection University College of Nursing
NUR 4641: Adult Health II
SOAP Form
Student’s Name Date: _________
Patient’s Initials:
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Patient Demographics
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Chief Complaint
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Assessment and Interventions Done Today
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Include age, gender, ethnicity, occupation and other demographics, who they live with, location, housing, PMH/PSH, medications and purpose, allergies pertinent to the health status.
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Identify why the patient is at the site today. When possible use the patient’s words/chief complaint.
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Use SOAP format for the assessment data following a head-to-toe assessment, when applicable. Identify interventions done today, and anticipated before or @ next visit (e.g., procedures employed, medications prescribed, patient education, referrals or support systems enacted). Interventions should relate to the reason for the visit as well as the health risk, health alteration and demographics of the patient. Include medical and nursing dx.
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Demographics:
PMH:
PSH:
Allergies:
Medications:
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S
O:
A:
Medical Diagnosis
Nursing Diagnosis:
P:
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Additional Information
Self-evaluation/summary
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Patient’s information:
86-year-old female with history of A fibrillation on Eliquis, Hypertension, Heart failure presenting to the ED for evaluation in increasing weight of 7lbs over the last 2 week with an increase orthopnea, intermittent dyspnea and fatigue over the last several days. Her daughter who notices the new findings contacted the health care provider. Upon arrival, patient endorses the above symptoms along with non- productive cough, occasional tightness. She states she sleeps with pillow at home. She denies recent illness, fever, chill, vomiting, abdominal pain, diarrhea, constipation, blood in her urine or stool. She is vaccinated for covid-19 with her booster administration.
Diagnosis: Hypertension
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