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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