NURS 611 Video Recorded Health Assessment Exam and Write-Up See your Bates

NURS 611 Video Recorded Health Assessment Exam and Write-Up

See your Bates Guide to Physical Examination for excellent examples of complete
H & P and SOAP note formats:

https://clasesmedicas.files.wordpress.com/2017/01/bates-pocket-guide-to-physical-examination.pdf

S (subjective data):

Chief Complaint (CC); HPI: include symptom dimensions, chronological narrative of patient’s complains, information obtained from other sources (always identify source if not the patient). Pertinent past health history: Medical history (list diagnoses and duration); Surgical history (surgical and procedures with year); Allergies: describe type (medication, food, environmental, topical/skin); Pertinent review of systems; Current medications (list with daily dosages, frequencies, routes); Personal and Social history: Include occupation, last year of schooling; home situation, stress (current and past), military service; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs). Also include lifestyle habits such as exercise and diet, safety measures, and alternative health care practices.

O (objective data):

Vital signs including oxygen saturation when applicable; Focuses physical exam; All pertinent labs, x-rays, etc. if applicable.

A (assessment/problem list):

Assessment: A one sentence description of the patient and major problem;
Problem list: A numerical list of problems identified
All listed problems need to be supported by findings in subjective and objective areas above. Try to take the assessment of the major problem to the highest level of diagnosis that you can. Provide at least two (2) differential diagnoses for the major new problem identified in your note.

P (plan): Your plan for the patient based on the problems you’ve identified

Therapeutic Interventions: Develop a diagnostic and treatment plan for each differential diagnosis. Your diagnostic plan may include tests, procedures, other laboratory studies, consultations, etc. Educational Interventions: Your treatment plan includes patient education, pharmacotherapy if any, other therapeutic procedures. You must also address plans for follow-up (next scheduled visit, possible consults/referrals etc.). Empathic interventions: Describe your communication to reflect patient/family psychosocial support. Discuss possible social services, self-help groups, and referrals to address his substance abuse.