MN552 Advanced Health Assessment
Unit 3 SOAP Note Section II and III Written Guide
1. Document appropriate data in the relevant body system.
a. Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider.
2. This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history.
3. Address each component of the SOAP note as noted in the written guide with relevant data.
4. You may continue with the same volunteer to complete each section of the SOAP note.
II. Life style patterns
0. Immigrant status
0. Spiritual resources/religion
0. Health perception
0. Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type
0. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence
0. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins
0. Occupational health: Known exposure to environmental toxins at work
0. Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook)
0. Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family
0. Cognitive function: Memory; speech; judgment; senses
0. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep
0. Exercise patterns: Type and frequency
0. Hobbies/recreation: Leisure activities; any travel outside of the US
0. Social habits: Tobacco; alcohol; street drug use
0. Intimate partner violence (review screening questions on page 58 in the Jarvis textbook)
0. Coping/stress management: Any major life change in past 2 years; do you feel tense; source; what helps
0. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function
III. Review of Symptoms
| 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 | |
| Head | Headache; head injury; dizziness or vertigo | |
| Eyes
|
Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma | |
| 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 | |
| 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 | |
| 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 | |
| Cardiac | Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD | |
| 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 | |
| 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 | |
| Heme | Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation | |
| Endo | Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distribution | |
| Psych | Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses |
