SOAP Note S: SUBJECTIVE DATA CC: “I have been having frequent headaches that are becoming more debilitating.” HPI: The patient is a 19-year-old female with a history of headaches since her teenage years. The headaches have recently become more debilitating, occurring once or twice a month and lasting up to 2 days. The pain begins […]

Focused SOAP Note Patient Information: S.T, 53, M, White S. CC (chief complaint): Forgetfulness, seeing imaginary things and sounds, and losing touch of reality. These symptoms have been increasingly concerning to both the patient and his family. HPI: S.T is a 53-year-old patient who is brought to the clinic by his sister due to the […]

Week 4: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation College of Nursing-PMHNP, Walden University NRNP 6645: Psychotherapy with Multiple Modalities Patient Initials: Edwin Age: 24 Gender: M Ethnic group: Hispanic Subjective: CC (chief complaint): “I feel trapped; I feel like I can’t escape my depression; it seems to bring me back to feeling down […]

Focused SOAP Note Patient Information: D, 72-years old female. S. Chief Complaint (CC): Debilitating headache and neck pain HPI: Dickson is a 72-year old female who comes to the clinic with a debilitating headache and neck pain. The patient complains that the problem is not new, but has worsened in the last week and currently […]