MN552 Advanced Health Assessment
Comprehensive SOAP Note Written Guide
This guide will assist you to document history data and perform a comprehensive physical exam in an organized and systematic manner. Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the general appearance, HEENT, neck, heart, and lungs for a focused/episodic exam. However, this Assignment requires assessment of all body systems. The pertinent positive findings should be relevant to the chief complaint and health history data. Please follow the guide and include all previous sections of the SOAP note with corrections based on feedback, as well as the Objective and Plan sections.
I. Subjective data
Date of History/Interview:
Source of history and Reliability: (client, family member, chart/record, etc.-sample on page 50 of Jarvis textbook)
P – Provocative or palliative (What brings it on? What makes it better or worse?)
Q – Quality or quantity (Describe the character and location of the symptoms; How does it look, feel, sound?)
R – Region or radiation (Where is it? Does the symptom radiate to other areas of the body?).
S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).
T – Timing (Inquire about time of onset, duration, frequency, etc.)
U – Understand Patient’s Perception of the problem (What do you think it means?)
(spontaneous or induced), number of children living
II. Life style patterns
III. Review of Symptoms
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Symptoms to Inquire About (please see page 54–56 in Jarvis textbook) |
Document pertinent negatives and/or positives The first system is addressed to provide a guide |
General |
Wgt Δ; weakness; fatigue; fevers |
Pertinent negatives: No weight gain or losses; no weaknesses, fatigue, or fevers Pertinent positives: Positive weight gain over past 2 months with fatigue and weakness; no fevers |
Skin |
Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails |
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Head |
Headache; head injury; dizziness or vertigo |
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Eyes |
Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma |
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Ears |
Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use |
|
Nose/ Sinuses |
Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain |
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Throat/ Mouth |
Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste |
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Neck |
Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion |
|
Breasts |
Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area |
|
Pulmonary |
Cough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest x-ray, TB skin test |
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Cardiac |
Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD |
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G/I |
Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance |
|
GU |
Frequency; nocturia; urgency; dysuria; hematuria; incontinence Females: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps; menopause; hot flashes; post-menopausal bleeding; Males: Caliber of urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often |
|
Peripheral Vascular |
Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers |
|
Musculo-skeletal |
Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease |
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Neuro |
Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations |
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Heme |
Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation |
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Endo |
Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distribution |
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Psych |
Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses |
IV. Objective Data
General:
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Skin:
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HEENT & Sinuses:
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Neck & Regional Lymph Nodes:
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Breasts:
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Lungs & Thorax:
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Heart:
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Gastrointestinal:
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Genitourinary:
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Extremities (Peripheral Vascular):
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Musculoskeletal:
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Neurological:
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V. Assessment
A: Differential Diagnosis (include rationales and cite sources)
1.
2.
3.
B: Nursing Diagnosis
1.
C: Medical Diagnosis
VI. PLAN
A: Orders
B: Follow-up plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit — F/U in 2 weeks; plan to check annual labs on RTC (return to clinic).
VII. Nursing theory and application: Select a nursing theory and apply this to your patient’s plan and evaluation (brief statement).
VIII. Developmental stage: Identify the developmental state and provide rationales to support acquisition of skills in the stage (brief statement).
IX. Cultural characteristics, diversity, sensitivity, and ethical considerations
Discuss culturally diverse considerations you identified for this patient. Cultural diversity is a general term that can include gender, religious beliefs, culture, race, economic status, age, etc. Discuss one ethical standard relevant to the care of this patient.
X. Evaluation of care: Provide a brief statement sharing your thoughts about the visit and/or patient. Please share what you should have done differently.
References: Please include a minimum of three references. The reference list must be in APA format. All sources must be within 5 years of publication.
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