Question

I am confused with how to write this in a ROS format opposed to narritive. this is for a respiratory soap note

SUBJECTIVE:  

Patient is a 45-year-old-caucasion female. Patient has been experiencing cough with excessive sputum, shortness of breath, fever, achy chest pain, and a headache upon wakening for the last 3 days. Patient explains that pain increases when she is exerting energy such as climbing a flight of stairs or chasing after her 2-year-old niece. Her pain is constant, and prominent when she inhales. Patient reports that when she is sedentary, pain is eased.

Answer 1

SOAP note

Subjective- $5 year old caucasion female, experiencing cough with sputum, shortness of breath, chest pain and headache is reported. The pain enhancing due to work and exertion and climbing stairs. Pain is relieved on being sedentary.

Objective-

The patient is febrile, with headache, and chest pain. The patient looks pale, fatigued and struggling with breaths.

Assessment-

The physical assessment reveals febrile skin with paleness, the patient has wheezes on auscultation with difficulty in breathing and pain during expiration.

Plan-

The patient is prescribed some bronchodialators, and nursing interventions are administered, the intervetion include use of pillow while coughing and expectoration of excessive cough and sputum.