NUR2180 Physical Assessment
Define the Subjective, Objective, Assessment, and Plan components of a SOAP note.
• Organize pertinent positive and negative aspects of the history in the Subjective portion of the note.
• Organize pertinent positive and negative findings of the physical examination in the Objective portion of the note.
• Generate Assessments by analyzing information from the Subjective and Objective portions of the note.
• Document Assessments using terminology consistent with International Classification of Diseases, 9th Revision (ICD-9) codes.
• Identify components of patient management that should be documented in the Plan section of the note.
• Evaluate sample SOAP notes and complete worksheets.
Based on this example, answer the following questions:
1. How long has the patient had left knee pain?
2. Has he tried anything to relieve the pain?
3. What pertinent positives and negatives are documented? Should any other pertinent elements have been documented?
4. Does the patient have any chronic medical conditions?
5. Has the patient had any surgery?
6. Does the patient take any medications?
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