Clinical Analysis of a Patients Documents

Assignment Instructions

One comprehensive health history is required for an adult patient over age 21.
Using the comprehensive health history guide (file attached), obtain a comprehensive health history from a simulated “patient”. Please identify a person (could be a classmate!) To complete this assignment so that you get practice interviewing a person.
The purpose of the assignment is not to uncover personal, sensitive information but to practice taking a complete history. Therefore, please advise your “patient” that personal or sensitive questions should not be answered truthfully.

• The assignment should be submitted using the provided template.

o The most common mistakes made in this assignment is confusing subjective and objective data. Make sure you check your work to make sure you are not including objective information.

o Formatting matters. We are not looking for paragraphs. This should look like an actual SOAP note in clinic, easy to read, succinct, and with pertinent information.

o Should not be in APA format.
o Don’t just write out a made-up history – actually interview ‘a patient’ and practice asking the history questions. It is very good practice to actually practice asking the questions and learning about communication skills as an advanced practice nurse.

The clinical SOAP note is essential to patient care. The goal is to convey clear, concise, and comprehensive information that documents key findings. Your audience for this record could be a variety of providers (primary care, acute care, specialists). Because the SOAP note is a legal record, adopting certain practices is important. The amount of detail you include and the consistency with which you document needs to be established early. Additionally, documentation has the potential to be/show bias that results in poor patient care and outcomes. Therefore, careful understanding of this and dedicated commitment to avoiding bias is critical.
The components of a SOAP note are:

1. Subjective (S): In this section, the healthcare provider records information that the patient has expressed subjectively, such as symptoms, feelings, concerns, and their medical history. This can include the patient’s description of their current problem, any changes since the last visit, and how they’re feeling overall. Information in the subjective section is gathered through interviews and conversations with the patient.
2. Objective (O): The objective section contains objective and measurable data collected during the patient encounter. This includes physical examination findings, vital signs (such as blood pressure, heart rate, temperature), laboratory results, diagnostic test results, and any other relevant observations.
3. Assessment (A): In this section, the healthcare provider offers their professional assessment or analysis of the patient’s condition. This includes the provider’s interpretation of the subjective and objective information and their working diagnosis or impressions.
4. Plan (P): The plan section outlines the proposed or ongoing management and treatment strategies for the patient. This includes any prescribed medications, recommended interventions including health promotion and disease prevention, further diagnostic tests, referrals to specialists, and patient education. The plan also details the timeline for follow-up visits and any specific instructions the patient needs to follow.

Common language: Begin to think about how to communicate, written and orally, using provider neutral, non-biased, widely accepted provider language.
• Example of provider neutral language: saying “providers” or “physicians” rather than saying “doctors” or “mid-levels”
• Example of non-biased language: Taken from the Words Matter article: “28 old male w/ history of sickle cell who typically requires opioid pain medication in the ED” rather than “28 old male with sickle cell who is narcotic dependent and frequently in the ED”
• Example of widely accepted provider language: “The patient has decreased flexion to left elbow” rather than “The patient is unable to bend the elbow”.