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Aug 27, 2018·Today, the patient’s vital signs were as follows: BP 162/82, Pulse 64 and regular, Respirations 20 per minute, and pulse ox 98% on 2L Oxygen via nasal cannula. His lungs are diminished with scattered crackles. Bowel sounds are active, and the patient had a bowel movement x 2 today, both soft. Incontinent of urine and wearing a diaper.

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Free SOAP Note Templates: How to Write & Examples ...

Aug 17, 2021·SOAP Note Example: Objective: Vital signs represent a temperature of 39°, BP of 130/80. Patient displays rashes, swollen lymph nodes and red throat with white patches. Assessment – What You Think is Going on. This section tells the diagnosis or what condition the patient has. The assessment is based on the findings indicated in the ...

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Jan 08, 2021·Objective. The objective section needs to include your objective observations, which are things you can measure, see, hear, feel or smell.. Objective observations Appearance. Document the patient’s appearance (e.g.“The patient appeared to be very pale and in significant discomfort.”). Vital signs

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