Health assessment

Health assessment
Comprehensive SOAP Template

This template is for a full history and physical. For this course include only areas that are related to the case.

Patient Initials: _______ Age: _______ Gender: _______

Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and
billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must
include the seven attributes of each principal symptom in paragraph form not a list:

1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations

Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdap, Flu, pneumonia, etc.

Significant Family History: Include history of parents, grandparents, siblings, and children.

Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that
address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you so ensure that you include all
essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the
CC, HPI, and History unless you are doing a total H&P- only in this course. Do not use “WNL” or “normal.” You must describe what you see.

Physical Exam:
Vital signs: Include vital signs, ht, wt, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial
expression, manner, level of consciousness, and affect and reactions to people and things.
HEENT:
Neck:
Chest
Lungs:
Heart
Peripheral Vascular: Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.

ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence
and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in
your treatment plan.

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Treatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals,
consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health
promotion recommendations and strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography,
colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

REFLECTION: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. Reflect on your clinical experience,
and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
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