MN 552 Unit 2 SOAP Note Section I Written Guide

Mia Meny RN

MN552 Advanced Health Assessment

Unit 2 SOAP Note Section I Written Guide

10/31/2016

Date of History/Interview: 10/30/2016

Source of history and Reliability: Patient

P – Greasy food, moving around after eating, certain smells.

1. Biographical Data
   1. H.G
   2. 2067 W St Rd 340 Brazil, Indiana
   3. 812-821-3921
   4. English
   5. J.G Husband
   6. 33 – 7/8/1983
   7. Goshen, IN
   8. Female
   9. Caucasion
   10. Married x3 yrs
   11. “American”
   12. Bachelors degree
   13. RN –ADON
   14. Anthem
2. Chief Complaint Nausea/Vomiting
   1. “I have been throwing up for weeks and feel very ill”
   2. Approximately 3 weeks ago
3. History of Present Illness:

Q – Some days no nausea/vomiting other days it is almost constant. It is better at night right before bed and seems worse in the mid morning. Whenever nausea is present the patient states she always vomits.

R – Nauseated in the stomach area, denies dizziness. Pt denies any cramping.

S – 7

T – Nausea lasts 1-2 hrs and ends with vomiting 1-2 times. On average it occurs 1-2 times per day. With an occasional day off.

U – “That I am sick”