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Nursing N830 Soap Note Comprehensive

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John Marsh
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College of Our Lady of the Elms

Nursing (Nursing)

N830 Soap Note Comprehensive

HPI Documentation
1.Onset Reports head and throat aches started about two days ago
2. Location
Include radiation Throat and head. Pain does not radiate
3.Duration:
Reports head and throat aches being constant and lasting for two days
4. Character:
Burning and sore
5. Associated s/s
fatigue and fever.
6. Relieving and
Aggravating factors Drinking cold water helps to alleviate the throat pain temporarily. Swallowing makes the throat
pain worse. No aggravating or alleviating factors related to headache.
7.Temporal
Constant head and throat pain during the day but is worse upon awakening.
8. Severity
Acute; rates his pain to both head and throat a “5/10”.

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Nursing N830 Soap Note Comprehensive

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