Case Study for SOAPIER Note.
Read the case study. Write a progress note using the SOAPIER format.
SJ came to the ER you are working at with complaint of severe pain in his left leg. When you asked him what happened, he said “I was sled riding in the snow with some friends. I lost control and went over the hill and hit a tree. My leg is killing me.”
You do an assessment. SJ is alert and oriented to person, place and time. He has no known allergies (NKA).Skin is warm and dry. Color appropriate for ethnicity. Neuro checks are normal. Denies hitting his head. Has full range of motion in both arm and right leg. EMS has a stabilizing splint on his right leg. Bilateral toes are pink and capillary refill is quick to return. Distal extremities pulses are strong and bounding. Bowel sounds are positive in all four quadrants.
Vital signs are 97.8 orally. Heart rate is 110 and regular. Heart sounds S1 and S2 heard. Respirations are 24 and unlabored. Lung sounds are clear. Blood pressure is 172/96. He asks “Please can you give me something for pain?” Rates his pain a “10” on the 0 -10 numeric scale. You give him 4 milligrams of morphine IV as prescribed by the physician.
The xray results come back and he has a complete fractured tibia. He is admitted to the medical/surgical unit and scheduled for surgery tomorrow. Report given to RN “Mary” on the medical/surgical unit.