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: Born in San Diego, California. U.S. Citizen
0. Spiritual resources/religion: Christian
0. Health perception: Fair
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: Healthy appetite, stressed over recent weight gain, eats 3 meals per day and snacks in between meals, patient admits she could benefit from eating healthier, and reduce portions. Patient states she does not drink enough water, her intake is about 48oz of fluids a day that include water, coffee, juices and tea. No cultural restrictions.
0. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence. Daily bowel movement no use of laxatives, polyuria, frequent urination throughout the day, no bedwetting at night, narrowed stream, no incontinence, but sometimes has small void when she sneezes.
0. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins: Lives in a city, urban community, owns her own home, no known exposure to environmental toxins, other than we she goes downtown and sees buses drive by.
0. Occupational health: Known exposure to environmental toxins at work. No known exposure to toxins at work, her work is a no smoking environment.
0. Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook): Patient is 65 y/o and is independent with ADLs, very social, meets with friends to play cards once a week. Patient has a driver’s license in the state of California and drives.
0. Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family: Patient was married but currently divorced, lives with daughter and teenage grandson, patient independent and makes own decisions regarding health and daily activities, she is also an active member at church, pays her own bills, is very capable of managing every day schedules.
0. Cognitive function: Memory; speech; judgment; senses: Memory appropriate for her age, clear speech pattern.
0. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep. Sleeps approximately 7 hours at night, does not nap in the day, uses 2 pillows, does not use sleep aids in the form of OTC pills, she does enjoy a hot cup of tea at bedtime that helps her relax.
0. Exercise patterns: Type and frequency: Enjoys walks in the park, walks 3 days out of 7 days.
0. Hobbies/recreation: Leisure activities; any travel outside of the US: Enjoys playing cards, and watching movies when possible, has not traveled recently out of the USA but has traveled in the past to Colombia, South America.
0. Social habits: Tobacco; alcohol; street drug use: Does not drink socially or smoke cigarettes, has never experienced street drugs.
0. Coping/stress management: Any major life changes in past 2 years; do you feel tense; source; what helps: No major changes in the past 2 years, her divorce was 10 years ago, patient states at first it was hard to adapt but has coped well over the years and feels emotionally healthy. At moments of tension, patient enjoys relaxing over a nice walk in the park.
0. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function: Currently not sexually active, of heterosexual orientation, major changes in her sexual health has been abstinence since her divorce which she feels comfortable with, patient states that in this stage of life she prefers to be alone and enjoy her family.
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||No skin rash, lumps, sores, minimal skin dryness, no itching, no pigmentation changes in skin other than appropriate for age.|
|Head||Headache; head injury; dizziness or vertigo||No head injuries, no headaches, no problems with vertigo, or dizziness.|
|Eyes||Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma||No eye pain, no redness, or swelling, change in vision appropriate for age, wears reading glasses, last eye exam a year ago, no tearing, double vision, blurred vision, or scotoma.|
|Ears||Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use||No tinnitus, no earaches, or infections, no discharges, no changes in hearing, no need for use of hearing aids.|
|Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain||No recent colds, congestion, or nasal obstruction, no nasal drainage or discharge, no itching, hay fever or allergies but is sensitive to strong odors. No H/O of nosebleeds, No sinus pains.|
|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||Sensitive gums with minimum bleeding when flossing, no mouth pain or sores, no lesions in mouth or tongue, wears dentures, last dental exam was in 6 months ago, no sore throat or hoarseness, no tonsillectomy, or noticed change in taste buds.|
|Neck||Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion||No palpable or visible lumps, enlarged or tender nodes, no swollen glands, no goiter, slight pain in neck due to degenerative changes, slight stiffness towards the end of the day, No limitation of motion, right and left neck rotations, and next extensions appropriate.|
|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||No visible or palpable right and breast lumps, no pain, discomfort, nipple discharge, rash or surgeries, no history of breast disease, performs self-breast exams monthly, last mammogram one year ago, no lumps, tenderness or rash of bilateral axilla’s.|
|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||Positive productive cough, no hemoptysis, dyspnea, or wheezing, no pleuritic pains with cough or on inspiration, no active H/O of lung disease, toxin or pollution exposure, last Chest x-ray, and TB one year ago.|
|Cardiac||Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD||No chest pain or discomfort., no palpitations, dyspnea, orthopnea edema, cyanosis. Positive for nocturia, 2 to 3 times a night. No 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||Good appetite, no jaundice, nausea, emesis, dysphagia, positive for heartburn associated with food, no pain, positive for belching, no flatulence. No hematochezia in stool or with bowel movement, melena, hemorrhoids or constipation. No diarrhea, or 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
|Positive for nocturia, 2 to 3 times a night, no urgency, dysuria, hematuria or incontinence. No H/O education of kegal exercises after birth. No current use of birth control, negative for HIV exposure. Menarche at age 12, 28-day cycle, duration of menses 3 to 4 days. No dysmenorrhea, positive PMS symptoms that included mild pain. No bleeding between menses, or after intercourse when was sexually active, LMP 9 years ago, no vaginal discharge, itching, sores or lumps. Menopause at age 56, no hot flashes, no post-menopausal bleeding.|
|Peripheral Vascular||Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers||Positive claudication, no coldness, tingling or numbness, positive leg cramps, varicose veins. No H/O of blood clots, discoloration of the hands or ulcers.|
|Musculo-skeletal||Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease||Positive for muscle, joint pain, and cramps associated with age, minimal joint stiffness, no H/O arthritis, or Gout, no limitation of movement or 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||No syncope, seizures, weakness, paralysis, stroke, numbness/tingling or tremors or tics, No involuntary movements, coordination problems, memory disorder or mood change, No H/O of mental disorder or hallucinations.|
|Heme||Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation||No H/O anemia, easy bruising or bleeding. No blood transfusions or reactions. No 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||No heat or cold intolerance, no excessive sweating, polydipsia, or polyphagia. Positive polyuria. H/O diabetes type 2, no H/O thyroid disease, hormone replacement, or abnormal hair distribution.|
|Psych||Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses||No nervousness/anxiety, depression, or memory changes. No suicide attempts or H/O mental illness.|