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.