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Nursing SOAP Note

Nurses can use this SOAP note template to collect patient’s information for admission purposes. Use this checklist to take digital notes of the patient’s matters and needs. Collect information needed for medication by documenting the results of physical observations and laboratory tests.
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Nursing SOAP Note

Inspection

Subjective Data

Chief complaint:

History of present illness:

History of past illness:

Social History (e.g. does the patient smoke/ do enough sports,...)

Family History:

Review of Systems:

Is the patient taking any medication?

Does the patient have any allergies?

Objective Data

Age:

Height (in inches):

Weight (in lbs):

BMI:

Gender:

General Appearance:

Blood Pressure:

Body temperature:

Any different appearances regarding eyes, ears, nose, throat?

Respiratory:

Cardiovascular:

Integument/ Lymphatic Inspection:

Laboratory Results:

Assessment

General Observations:

Differential Diagnosis:

Plan

Any other notes:

Completion

Nurse's Name & Signature:

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