Chest Pain SOAP Note Documentation
1. Situation
Brian Foster is a 58 year-old man currently experiencing chest pain. He rates the pain at 6/10 anddescribed it as a constant squeezing pressure. He reports pressure in his left shoulder and a briefspell of nausea upon the onset of chest pain but denies other accompanying systems.Model NoteBrian Foster is a 58-year-old man currently experiencing chest pain. He rates the pain at 6/10 anddescribed it as a constant squeezing pressure. He reports pressure in his left shoulder and a briefspell of nausea upon onset of the chest pain, but denies other accompanying symptoms.
2. Background
Mr Foster is post-op day 3 for a TURP. His post operative course was normal until the chest pain thismorning. He has a history of hypertension, hyperlipidemia and family history of cardiac disease. Hedoes not smoke.Model NoteMr. Foster is post-op day 3 for a TURP (Transurethral resection of the prostate). His post-operativecourse was normal until the chest pain this morning. He has a history of hypertension,hyperlipidemia, and family history of cardiac disease. He does not smoke.