MN552 Advanced Health Assessment Comprehensive SOAP Note Written Guide
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MN552
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MN552
MN552 Advanced Health Assessment Comprehensive SOAP Note Written Guide/MN552 Advanced Health Assessment Comprehensive SOAP Note Written Guide/MN552 Advanced Health Assessment Comprehensive SOAP Note Written Guide
mn552 advanced health assessment comprehensive soap note written guide
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MN552 Advanced Health Assessment
Comprehensive SOAP Note Written Guide
This guide will assist you to document history data and perform a comprehensive physical exam
in an organized and systematic manner. Please include a heart exam and lung exam on all clients
regardless of the reason for seeking care. So, if someone presented with cough and cold
symptoms, you would examine the general appearance, HEENT, neck, heart, and lungs for a
focused/episodic exam. However, this Assignment requires assessment of all body systems. The
pertinent positive findings should be relevant to the chief complaint and health history data.
Please follow the guide and include all previous sections of the SOAP note with corrections
based on feedback, as well as the Objective and Plan sections.
I. Subjective data
Date of History/Interview: 1/16/18. Patient is describing the day when he had his heart attack. He
currently denies any symptoms and reports having no chest pain currently. His MI was in 2003.
Source of history and Reliability: (client, family member, chart/record, etc.-sample on page 50 of
Jarvis textbook)
1. Biographical Data
a. Name (use initials only) DC
b. Address 1218 Fair Street Mankato, MN, 56001
c. Phone number- 507-340-2382
d. Primary language- English
e. Authorized representative- Self
f. Age and Date of Birth- 67, 10/25/1950
g. Place of Birth-Iowa City, IA
h. Gender- Male
i. Race- Caucasian
j. Marital Status- Divorced
k. Ethnic/Cultural Origin- German, Scottish and Irish
l. Education (highest level completed)- High School Diploma
m. Occupation/Professional- Retired
, 2
n. Health insurance- VA
2. Chief Complaint (reason for seeking health care): Chest Pain
a. Brief spontaneous statement in client’s own words- I was sitting in a chair and felt tired and short
of breath and had some pain in my chest and sat down to rest a little bit. I then called the ambulance
and they brought me here.
b. Includes when the problem started ( “chest pain for 2 hours”)- I’ve been having chest pain off/on
for about 5-6 months and thought it was just gas. It would last 10-15 minutes and then I’d belch and
the pain would go away.
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 (What brings it on? What makes it better or worse?)- Doing normal
stuff. When I’d belch the pain would go away and then I’d think I was fine because I thought it was
indigestion.
Q – Quality or quantity (Describe the character and location of the symptoms; How does it look, feel,
sound?)- Right here in the center of my chest. It was just tightness and like I was full of gas or
something
R – Region or radiation (Where is it? Does the symptom radiate to other areas of the body?). Center
of my chest. No radiation, just right in the center of my chest.
S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10). 6/10
T – Timing (Inquire about time of onset, duration, frequency, etc.) It would come on about 2-3 times
per day and last about 10-15 minutes.
U – Understand Patient’s Perception of the problem (What do you think it means?) I thought it was
indigestion because it would go away.
4. Past Medical History
a. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and
disabilities- Myocardial Infarction with angiogram with stent placement in 2003. 1977-Throat injury
from farm accident, fractured ankle 2012 (left), CVA-2016 with hospitalization. No blood
transfusions. Does have some residual numbness/tingling and weakness on the left side since CVA
including some slurred speech and drooling. Hearing Impaired in right ear.
b. Childhood Illnesses: Measles, mumps, rubella, chickenpox
, 3
c. Surgical Hx; procedures, Throat injury in 1977 and stent in 2003
d. Obstetric HX: Not applicable
e. Immunizations- Influenza shot 2017, Pneumonia-2014, Zostavax-2015
f. Psychiatric Hx: None
g. Allergies: None
h. Current Medications: Aspirin 325mg (EC), once daily, Lisinopril 15mg once daily (1.5 tabs of
10mg), Atorvastatin 20mg daily.
i. Last Examination Date: Physical-July 2017, eye exam-September 2017, foot exam, dental exam-
1966, hearing screen-Not since I went into the service, 1970, EKG-March 2016, chest X-Ray-March
2016, serum cholesterol-July 2017, stool occult blood-Cologuard March 2017, prostate-Can’t
remember last time, PSA-July 2017, UA-2012, TB skin test-as a child;
5. Family History (list FHx and design a genogram (computer)-include a key with the genogram).
The Genogram must include 3 generations.
a. Include parents, grandparents, spouse, and children. Alreta Crock-Heart Disease and Dementia,
Herbert Crock-Diabetes, Kidney Failure, Cancer of Spine, Maternal Grandparents- Mary Cruse-
Diabetes, Joseph Cruse-Heart Attack, Paternal Grandparents-Inez Crock-Diabetes, Heart Attack,
Leander Crock-Heart Attack, Stroke, Son-Brian-No medical diagnoses-Living
b. Health conditions, familial and communicable diseases/illnesses
c. Note whether family member deceased or living
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