Soap Note for Nursing
Patient presents with chief complaint of _____. Patient reports that the pain is a ___ out of ten and has been present for ____ weeks/months. patient denies any other symptoms associated with this complaint.
On physical examination, patient appears to be in no distress. vital signs are stable and within normal limits. There is tenderness to palpation at _____ cm from the _____ spine. There is no guarding or rebound tenderness. Range of motion is within normal limits.
Based on the patient’s history and physical examination, it is most likely that the patient is suffering from _____. This is a condition characterized by _____.
The patient will be started on _____ for pain relief. The patient will be advised to follow up with their primary care physician in _____ weeks/months. In the meantime, the patient will be instructed to return to the emergency department if they develop any new or worsening symptoms.