CHIEF COMPLAINT: Mr Santos ,74 years old male with a

chief complaint of Back pain.

SUBJECTIVE Patient reports” I didn’t sleep last night”

Medical History: Hypertension

 States pain is 8 out of 10

Vital signs
OBJECTIVE
 BP 210/90
 P 72
 R 18

 A cute pain in the lower back that radiates to the

left leg.
ASSESSMENT

Continues to need narcotic medication for progress

toward goal of pain relief.
PLANNING
SOAP and DAR CHARTING
FOCUS DATA, ACTION and
response
Back Pain D. Patient requested pain
medication for sharp stabbing pain
in the lower back that radiates to
left leg. States pain 8 out of 10.

A.
 Positioned on side with
pillows behind back
 Heating pad applied to lower
back
 Last medicated 5 hours
previously
 Medication with ordered
analgesic

R. Patient response “I feel better”

after intervention.