absentsanity
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Im getting confused by my soap note handout and what soap acronym actually means... It says sample hx should be in objective but aren't questions like pertinent negatives subjective? I don't know maybe some of you could give me some notes, im so close to finishing this class just seemed to have been in space for the few times we went over this.
Here is what I have for one of my notes:
S:
I have a 77 year old male whose chief complaint is hip pain, states his level of pain is 1 out of 10.
Patient states he tripped and fell while fixing a gate at his church around 1:30pm, patient was found in an unknown position on cement driveway.
O:
Head to toe findings revealed a bump on the left hip and lateral rotation of left leg while lying supine patient denies being able to rotate left leg to a neutral position. Good CSM’s on left leg.
Vitals after arrival at ED 2:20pm:
LoC: A&OX4
Heart Rate: 69 strong and regular
Respiration Rate: 14 unlabored
Skin: Pink Warm and Dry
0xygen sat: 98
BP: 178/70
Pupils: PEARL
Patient denies drinking, street drugs, marijuana use, allergies to any medications, seizures, previous hip injury, heart problems, bridge dentures, and stroke.
Patient has point tenderness on his left hip, pain was rated 1 out of 10 in supine position, Patient is a type 2 diabetic and has a hernia, Last ins and outs are unknown. Medications taken are unknown (I didn’t ask, nurse seemed to know him).
A:
Possible Hip Fracture
P:
Patient was given warm blanket and ice on his hip, and then taken for an X-ray.
X-ray revealed a hip fracture and patient was scheduled for surgery the next morning. Monitoring patient for any changes.
Here is what I have for one of my notes:
S:
I have a 77 year old male whose chief complaint is hip pain, states his level of pain is 1 out of 10.
Patient states he tripped and fell while fixing a gate at his church around 1:30pm, patient was found in an unknown position on cement driveway.
O:
Head to toe findings revealed a bump on the left hip and lateral rotation of left leg while lying supine patient denies being able to rotate left leg to a neutral position. Good CSM’s on left leg.
Vitals after arrival at ED 2:20pm:
LoC: A&OX4
Heart Rate: 69 strong and regular
Respiration Rate: 14 unlabored
Skin: Pink Warm and Dry
0xygen sat: 98
BP: 178/70
Pupils: PEARL
Patient denies drinking, street drugs, marijuana use, allergies to any medications, seizures, previous hip injury, heart problems, bridge dentures, and stroke.
Patient has point tenderness on his left hip, pain was rated 1 out of 10 in supine position, Patient is a type 2 diabetic and has a hernia, Last ins and outs are unknown. Medications taken are unknown (I didn’t ask, nurse seemed to know him).
A:
Possible Hip Fracture
P:
Patient was given warm blanket and ice on his hip, and then taken for an X-ray.
X-ray revealed a hip fracture and patient was scheduled for surgery the next morning. Monitoring patient for any changes.
