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.
