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Home » The SOAP note is a commonly used narrative transcription of a client’s health data.

The SOAP note is a commonly used narrative transcription of a client’s health data.

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The SOAP note is a commonly used narrative transcription of a client’s health data. It can be used to identify and explain the client’s problem-oriented complaint and comprehensive history. For this assignment, utilize the attached Word document to record a comprehensive history and client examination in a narrative format.

· Subjective Data: What the client or family members tell you about the client’s signs and symptoms and the reason for seeking healthcare. Typically, this is documented by quoting the actual words said.

· Past Medical History is subjective data the nurse collects about any past medical history.

· A review of systems is subjective data collected as a list of the body systems obtained through a series of questions to identify signs and/or symptoms the client may be experiencing.

· Objective Data: Factual, measurable clinical findings such as LOC, vital signs, and clinical findings on assessment.

· Assessment: Evaluating clinical findings through Inspection, Palpation, Percussion, and Auscultation. All information obtained is documented in the client’s history and pathophysiology.

· Plan: Short-term and long-term goals and strategies that will be used to relieve the client’s problems.

 

Complete the following template and submit documentation for the comprehensive health assessment.

 

Comprehensive Health Assessment Template

 

 

 

 

 

 

 

 

 

 

 

 

Comprehensive History and Patient Examination

 

Patient Name: ______________________________________________________________________ Age: ________ Sex: __________ Race: _________

Subjective Data Collection: Describe client chief complaint (C/C) in narrative format. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Past Medical History: Allergies______________________________________________________________________________

Medications: __________________________________________________________________________

Medical: _____________________________________________________________________________

Surgical: _____________________________________________________________________________

Health Maintenance: Last physical: ________________________________________________________

Immunizations and Date if known: _____________________________________________________________________________________

Recent travel or Military service: __________________________________________________________

Family Health History: _____________________________________________________________________________________Psychiatric Health History: _____________________________________________________________________________________

Nutritional Health History: _______________________________________________________________

Personal Habits: {Sleep patterns, health practices, Tobacco, Alcohol, Drugs, cultural/religious influences}____________________________________________________________________________

Review of systems (Subjective data):

HEENT: ______________________________________________________________________________

Cardiovascular: ________________________________________________________________________

Respiratory: ___________________________________________________________________________

Gastrointestinal: _______________________________________________________________________

Genitourinary: _________________________________________________________________________

Musculoskeletal: _______________________________________________________________________

Integumentary: ________________________________________________________________________

Neurological: __________________________________________________________________________

Endocrine:____________________________________________________________________________

Hematologic/Lymphatic:________________________________________________________________

Immunological:________________________________________________________________________

Female/Male Reproductive Organs: {Breast, Scrotal, Rectal, Vaginal}:

_____________________________________________________________________________________

_____________________________________________________________________________________

 

Physical Assessment (Objective data):

LOC: ______________________Appearance: ________________________ Speech: _______________

Clinical Findings: Describe patient assessment in narrative format.

Skin, Hair, Nails: __________________________________________________________________________________________________________________________________________________________________________

HEENT: _________________________________________________________________________________________________________________________________________________________________________

Respiratory system: __________________________________________________________________________________________________________________________________________________________________________

Cardiovascular system: __________________________________________________________________________________________________________________________________________________________________________Gastrointestinal system: __________________________________________________________________________________________________________________________________________________________________________

Genitourinary: __________________________________________________________________________________________________________________________________________________________________________

Musculoskeletal system: __________________________________________________________________________________________________________________________________________________________________________

Neurological system: __________________________________________________________________________________________________________________________________________________________________________

Functional Assessment: __________________________________________________________________________________________________________________________________________________________________________

ASSESSMENT: (problem list)

Example: Small circular wound to left lower leg.

1___________________________________________________________________________________

2.___________________________________________________________________________________ 3.___________________________________________________________________________________ 4.___________________________________________________________________________________5.___________________________________________________________________________________

 

PLAN: (Risk for each problem on the problem list and nursing recommendations for each problem)

Example: Client is at risk for infection with leg wound. Plan is to have client keep wound clean and bandaged.

1.___________________________________________________________________________________ ____________________________________________________________________________________ 2.__________________________________________________________________________________

_____________________________________________________________________________________3.________________________________________________________________________________________________________________________________________________________________________ 4.________________________________________________________________________________________________________________________________________________________________________ 5.________________________________________________________________________________________________________________________________________________________________________

Completed by: ________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

03/27/2023

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