Perfect Examples of Nursing SOAP Notes? EXAMPLE #1: Patient with Chest Pain and Shortness of Breath

EXAMPLE #1: Patient with Chest Pain and Shortness of Breath

Subjective:

Mr. Jones is a 71 y/o white male who presented to the ER yesterday at 0800 with intermittent chest pain and S.O.B. Pt. Reports pain has lasted off and on for the last six hours. He has a personal history of HTN, high cholesterol, and Type I DM. Family history positive for heart attacks, HTN, and Diabetes. After a 12-lead EKG, lab draw, and chest CT, pt. was diagnosed with transient angina. After being treated and stabilized in the ER, pt. was transferred to cardiac care for observation. Pt continues to complain of S.O.B. with ambulation but denies chest pain currently. No known allergies. Medication list provided and chart updated.

Objective:

Pt is A & O x4, pulses + x4 extremities. BP 146/90, R 24, HR 88, T 98.4, SpO2 92%. Lungs CTAB, HR regular. Skin is pale, warm, and dry, with slight cyanosis noted around lips. Pt walked from room to nurse’s desk with some S.O.B. noted on exertion.

Assessment:

Activity intolerance as evidenced by decreased SpO2, elevated respiratory rate, and cyanosis of lips.

Plan:

Apply O2 per NC @ 2L continuously, elevate HOB at least 45 degrees, encourage deep breathing exercises, continue to monitor vital signs and patient complaints, call light in place with instructions to call for assistance.

EXAMPLE #2: Patient with Productive Cough and Fever

Subjective:

Patient M.S. presented to the clinic with c/o persistent productive cough x5 days. She reports symptoms were first “like a cold,” but have progressively worsened in the last 48 hours. Use of OTC cough suppressant is minimally helpful. C/O some tightness in chest and difficulty taking deep breaths. Reports fever of 101.6 before coming to the clinic. Denies chills. Sputum is thick, mostly white, with a yellow tinge. No hemoptysis. Reports yellow nasal mucous when she blows her nose and facial tenderness.

Denies history of chronic pulmonary health issues but reports she is a smoker of 1 PPD x 20 years. Type 2 Diabetes is well-controlled on Ozempic 1 mg./weekly. Takes ASA 81mg qd prophylactically. No other prescripts or OTC medications. No significant personal or family medical history. No known drug or food allergies.

Objective:

Skin is pink, warm, and dry. Slight dyspnea on exertion noted when ambulating from bed to restroom. Vital Signs: B/P 120/78, P 84, R 26, T 100.2. Lungs CTAB. HR is steady, no murmurs, normal S1 and S2. No edema, pulses present x4 extremities. CXR negative for effusion or pneumonia. Heart is normal in size. Sinus x-ray series shows soft-tissue density causing sinus cavity expansion.

Assessment:

Recent onset of productive cough, purulent nasal drainage, facial tenderness, and low-grade temperature. CXR negative for pneumonia, no edema suggests the absence of CHF.

Plan:

Treat with albuterol inhaler 2 puffs q6hrs and Amoxicillin 500 mg. bid, as per MD orders. Instructed patient on the appropriate use of inhaler and coughing and deep breathing exercises; educated on smoking-related risks and encouraged smoking cessation; Instructed pt to follow up in clinic if no improvement and to go to ER with new or worsening symptoms.