MN552 Advanced Health Assessment

Unit 3 SOAP Note Section II and III Written Guide

1. Document appropriate data in the relevant body system.

a. Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider.

2. This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history. MN552 Soap Note Paper

3. Address each component of the SOAP note as noted in the written guide with relevant data.

4. You may continue with the same volunteer to complete each section of the SOAP note.

II. Life style patterns

0. Immigrant status

0. Spiritual resources/religion

0. Health perception

0. Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type

0. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence

0. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins

0. Occupational health: Known exposure to environmental toxins at work

0. Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook)

0. Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family

0. Cognitive function: Memory; speech; judgment; senses

0. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep

0. Exercise patterns: Type and frequency

0. Hobbies/recreation: Leisure activities; any travel outside of the US

0. Social habits: Tobacco; alcohol; street drug use

0. Intimate partner violence (review screening questions on page 58 in the Jarvis textbook)

0. Coping/stress management: Any major life change in past 2 years; do you feel tense; source; what helps

0. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function

III. Review of Symptoms

SOAP Note

Unit 2 SOAP Note Section I Written Guide

History, Interview, and Genogram Guide

Date of History/Interview: 23rd, September, 2017

Source of history and Reliability: (client)

1. Biographical Data

a. Name (use initials only): Mrs. W.W.

b. Address: George street, House no. 4, California

c. Phone number 305-555-5555

d. Primary language: speaks English

e. Authorized representative: her daughter

f. Age and Date of Birth: 50 y/o, July 15, 1967

g. Place of Birth: San Diego, California

h. Gender: female

i. Race: black

j. Marital Status: divorced

k. Ethnic/Cultural Origin: African

l. Education: master’s in criminology

m. Occupation/Professional: lecturer

n. Health insurance: full medical coverage

2. Chief Complaint (reason for seeking health care):

a. Brief spontaneous statement in client’s own words

“The cough started as a chest cough but it has not been better since my first time visit to the clinic. During the day it doesn’t bother me as much, but during the night I cough a lot. For the last few weeks I have experienced pain in the chest.” MN552 Soap Note Paper

b. Includes when the problem started

“I started coughing like three months ago. I have undergone treatment from regular hospitals but nothing seems to change.”

3. History of Present Illness: A well organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the PQRSTU pneumonic.

P – Provocative or palliative

The client states that in most cases room temperature affects her cough, when she feels cold she coughs more. She is also affected by strong smells like perfumes, and states that she cannot sit directly under a fan or air conditioner because the strong wind promotes her cough.

Q – Quality or quantity

The client feels pain in her chest when she coughs. Her throat is also sore. The cough produces sputum that seems clear.

R – Region or radiation

She only has coughing problem. No other complains.

S – Severity

The severity according to the patient is at 6 out of 10.

T – Timing

She states that when she starts coughing it can last for more than five minutes without stopping. She coughs mostly during the night or when she is irritated by a disturbing smell during the day or even strong wind.

U – Understand Patient’s Perception of the problem

Her fever seems low grade at 100 degrees without chills. After a long conversation with the client she says that she is worried she might have pneumonia. She has not had shortness of breath, she also denies postnasal drip. She has undergone chest X-rays, TB test, and taken many over the counter drugs and home remedies, with no improvement. MN552 Soap Note Paper

4. Past Medical History

a. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and disabilities.

No other major medical complications, she was diagnosed with diabetes at age 45, present concern is only her cough. hospitalized once for vaginal delivery, no other surgical hx.

b. Childhood Illnesses: Measles, chickenpox, Mumps, strep throat

c. Surgical Hx; dates, outpatient, X-rays.

Vaginal delivery on 02/26/1987, Chest X ray 08/15/2017

d. Obstetric HX:

Only one pregnancy, and one delivery, she gave birth to her daughter who is the only child.no miscarriages or abortion cases.

e. Immunizations: only as a child, immunization like MMR, Varicella, Tetanus, has not received busters as adult, but last visit to the doctor they gave her the flu shot. Patient states that she does not like getting vaccines.

f. Psychiatric Hx: no psychiatric conditions reported.

g. Allergies: allergic to dust

h. Current Medications: Metformin 500mg BID for diabetes type 2.

i. Last Examination Date: 12th March, 2017

No eye problem

No foot problem

There are some cavities

No hearing problem

EKG; normal

Chest X-Ray; diffuse wheezes are present bilaterally with expiration. No crackles or bronchi.

Pap test; no cervical cancer

Mammogram; no signs of breast cancer

Serum cholesterol; cholesterol level is at 200

Stool occult blood; no colon cancer

Prostate; not relevant

PSA; not relevant

UA; not collected

TB skin test; not detected

Sickle- cell; no sickle cell disease

PKU; non-applicable

Hamatocrit; 35% – normal

Genogram Three Generation

Section 2

This section has a family medical history as stated by the patient. Patient states that she is currently divorced from her husband whose whereabouts are unknown, prior to divorce he was in good health. Patient W.W. had one daughter with her ex-husband, she is alive and has history of asthma. Patient narrates that her mother is alive and heathy for her age, her father is deceased, he had a history of heart failure. Her maternal grandmother is alive and overall healthy, just debilitated due to her age, her maternal grandfather had a heart attack and is deceased. Patients grandmother is alive with arthritis, and her paternal grandfather is alive with diabetes. 

On the Ex-husband family side, she knows in his family in his mother’s side his mother is alive and with diabetes, his father alive and with hypertension, his grandmother had a stroke and is deceased, and his grandfather had committed suicide. On her Ex-husbands fathers side his grandmother alive with diabetes and HTN and his grandfather is alive with prostate issues and diagnosed with BPH. MN552 Soap Note Paper

ADDITIONAL INSTRUCTIONS FOR THE CLASS MN552 Soap Note Paper

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• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. MN552 Soap Note Paper

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. MN552 Soap Note Paper

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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