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15 questions
“I cut myself while cooking last week”
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Objective
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“Chest X-ray to be ordered and administer pain medications”
Subjective
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“Laceration measuring ½ inches is noted”s”
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“BP=138/74, HR 76”
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“start appropriate wound care”.
Subjective
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"I broke my leg this morning"
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“Problems: 1-gait deficits. 2-strength deficits. 3- orthostatic hypotension”
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-“ Edema in the right ankle has decreased 2 cm."
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“Patient to be seen twice weekly x 4 weeks”
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“Patient is oriented to time, place and person
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-“Patient will discharge to a rehabilitation center for alcohol addiction management”
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“Possible heart attack ”
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VITAL SIGNS would go under what category?
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WHEN DID IT OCCUR...HOW DID IT OCCUR? These questions belong to which section of a SOAP Note?
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