SOAPE NOTE
Name:_ Mrs. S
Focus: Cognitive Status
S: “My friend is not herself ” stated by friend visiting from
retirement home.
O: Patient appeared disinterested in visitors and was not
talkative, turning away during visits. Assessed and found to
have decreased levels of responsiveness. Did not eat meal tray.
Presenting with furrowed brow and moaning softly. ROM
delayed compared to previous day. Currently only orientated to
name. HR elevated compared to baseline.
A: Acute Confusio...
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