MN552 SOAP Note: Advanced practice nursing assessment
MN552 SOAP Note: Advanced practice nursing assessment
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.
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: Born in San Diego, California. U.S. Citizen
0. Spiritual resources/religion: Christian
0. Health perception: Fair
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: Healthy appetite, stressed over recent weight gain, eats 3 meals per day and snacks in between meals, patient admits she could benefit from eating healthier, and reduce portions. Patient states she does not drink enough water, her intake is about 48oz of fluids a day that include water, coffee, juices and tea. No cultural restrictions.
0. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence. Daily bowel movement no use of laxatives, polyuria, frequent urination throughout the day, no bedwetting at night, narrowed stream, no incontinence, but sometimes has small void when she sneezes.
0. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins: Lives in a city, urban community, owns her own home, no known exposure to environmental toxins, other than we she goes downtown and sees buses drive by.
