NSG 5540 CASE STUDY: COMPREHENSIVE SOAP NOTE
Sample COMPREHENSIVE SOAP NOTE COMPREHENSIVE SOAP NOTE Identifying Data: Age, Gender, Occupation, and Marital Status Initial: J.M Age: 8.5 Months Gender: Male Occupation: N/A Marital Status: N/A Source and Reliability: Mother to the Child who works as a nurse attendant. SUBJECTIVE: Chief complaint or appropriate health screening visit: The patient’s mother states, ‘I think my boy has an ear infection.’ HPI: JM is an eight-and-a-half-month-old baby boy who is healthy-looking and presented to the clinic by his mother with a likely infection on his right ear. The mother reports she noted something was amiss when she noticed the boy was pulling