Help with a SOAP note, (daily progress note) using 1995 guidelines, hospital visit.
S: Pt doing well, was very SOB today going to bathroom, 0 emesis, O2 sats down to 82% on RA, some cough, taking good PO.
O: VSS Afebrile
CV: RRR, 0 murmur
Resp: Bibasilar rales, 0 rhonchi
GI: bowel sounds +, nontender
Ext: 0 edema
A/P 1) ileus better, continue PO
2) CHF noted, IV thru INT, give lasix,
Re, check BMP in am, CXR, HGB
S: Pt doing well, was very SOB today going to bathroom, 0 emesis, O2 sats down to 82% on RA, some cough, taking good PO.
O: VSS Afebrile
CV: RRR, 0 murmur
Resp: Bibasilar rales, 0 rhonchi
GI: bowel sounds +, nontender
Ext: 0 edema
A/P 1) ileus better, continue PO
2) CHF noted, IV thru INT, give lasix,
Re, check BMP in am, CXR, HGB