NU552 Unit 2 Documenting Subjective information

Student Name

Purdue University Globle 

NU552 Advanced Health Assessment and Diagnostic Reasoning

Prof. Name

Date

How to Document Subjective Information, Conduct a Health History Interview, and Write a SOAP Note

A complete MN552 Advanced Health Assessment interview requires collecting accurate subjective information, documenting a comprehensive health history, performing a structured Review of Systems (ROS), and organizing findings into a SOAP note. Using a systematic interview process helps healthcare providers identify patient concerns, avoid missing important clinical details, develop appropriate differential diagnoses, and create an evidence-based plan of care.

Understanding the Purpose of the Subjective Health Assessment

The subjective portion of the health assessment gathers information directly from the patient through an organized interview. This information forms the foundation for clinical reasoning before any physical examination begins.

A structured interview ensures that important health information is collected consistently while improving communication between the healthcare provider and the patient. During the interview, the clinician should encourage open-ended responses, actively listen, and clarify any unclear information.

For this assignment, interview a volunteer family member or friend and document the subjective findings using the format below.

Documenting the Patient History

Begin the interview by recording the date of the assessment and identifying the source of the information. Also indicate whether the information provided appears reliable.

Biographical Information

Collect the patient’s demographic and background information, including:

• Patient initials only (do not use full names)

• Primary language

• Age and date of birth

• Place of birth

• Gender

• Race

• Marital status

• Ethnic or cultural background

• Highest education completed

• Occupation or profession

• Type of health insurance (commercial, private, state, or federal)

This information provides valuable context that may influence healthcare risks, communication, and treatment planning.

Documenting the Chief Complaint (CC)

The chief complaint is the patient’s primary reason for seeking healthcare.

Whenever possible, document the complaint using the patient’s exact words.

A properly documented chief complaint should include:

• The patient’s own description of the problem

• When the symptom began

Example

“I’ve had chest pain for the past two hours.”

Keeping the chief complaint brief and patient-centered improves documentation quality and supports accurate diagnosis.

Writing the History of Present Illness (HPI)

The History of Present Illness (HPI) is a chronological description of the patient’s current condition from symptom onset until the present visit.

One of the most widely accepted approaches for documenting an HPI is the OLD CARTS mnemonic.

OLD CARTS Assessment Framework

In addition, ask the patient about their own understanding of the illness:

“What do you think is causing this problem?”

The HPI should be written as a narrative paragraph rather than as individual answers.

Recording the Past Medical History (PMH)

A comprehensive Past Medical History helps identify previous illnesses, treatments, and health risks that may contribute to the current condition.

Include the Following Information

• Previous medical conditions

• Childhood illnesses (measles, mumps, rubella, chickenpox, pertussis, streptococcal infections)

• Surgical history with dates

• Hospitalizations

• Blood transfusions

• Obstetric history (when appropriate)

• Immunization status

• Psychiatric history

• Allergies and associated reactions

• Current prescription medications

• Over-the-counter medications

• Herbal supplements

• Previous preventive screenings and health maintenance examinations

Examples of preventive screenings include:

• Physical examination

• Eye examination

• Dental examination

• Hearing screening

• Electrocardiogram (ECG)

• Chest X-ray

• Pap smear

• Mammogram

• Serum cholesterol screening

• Stool occult blood testing

• Prostate examination

• Prostate-specific antigen (PSA)

• Urinalysis

• Tuberculosis screening

Documenting the Family History (FHx)

Family history identifies inherited conditions and familial disease patterns.

Include:

• Parents

• Grandparents

• Siblings

• Spouse

• Children

Document:

• Chronic illnesses

• Genetic disorders

• Communicable diseases

• Whether each family member is living or decease

Assessing Lifestyle and Health Patterns

Lifestyle factors frequently influence disease development and long-term health outcomes.

Areas to Assess

• Immigration history

• Religious or spiritual beliefs

• Personal perception of health

• Dietary habits

• Fluid intake

• Bowel and bladder patterns

• Living environment

• Occupational exposures

• Activities of Daily Living (ADLs)

• Instrumental Activities of Daily Living (IADLs)

• Family relationships

• Cognitive function

• Sleep habits

• Exercise routine

• Recreational activities

• International travel

• Tobacco use

• Alcohol consumption

• Recreational drug use

• Intimate partner violence screening

• Stress management

• Sexual history and reproductive health

These topics help identify psychosocial, environmental, and behavioral factors that influence patient care.

Performing the Review of Systems (ROS)

The Review of Systems is a head-to-toe assessment of symptoms reported by the patient. Both positive findings and pertinent negatives should be documented.

General

Assess:

• Weight changes

• Fatigue

• Weakness

• Fever

Pertinent Negative Example

Denies weight changes, fever, weakness, or fatigue.

Pertinent Positive Example

Reports weight gain over two months with fatigue and weakness but denies fever.

Skin

Assess:

• Rash

• Lesions

• Itching

• Dryness

• Hair changes

• Nail changes

• Color changes

Head

Assess:

• Headaches

• Head injury

• Dizziness

• Vertigo

Eyes

Assess:

• Vision changes

• Eye pain

• Redness

• Swelling

• Corrective lenses

• Last eye examination

• Excessive tearing

• Diplopia

• Blurred vision

• Scotoma

Ears

Assess:

• Hearing loss

• Tinnitus

• Ear pain

• Ear infections

• Ear drainage

• Hearing aid use

Nose and Sinuses

Assess:

• Nasal congestion

• Allergies

• Epistaxis

• Sinus pain

• Nasal discharge

• Changes in smell

Mouth and Throat

Assess:

• Dental problems

• Gum bleeding

• Mouth ulcers

• Dry mouth

• Hoarseness

• Sore throat

• Denture use

• Last dental examination

Neck

Assess:

• Swollen glands

• Neck pain

• Goiter

• Stiffness

• Range of motion

Breasts

Assess:

• Breast pain

• Lumps

• Nipple discharge

• Skin changes

• Previous breast disease

• Self-breast examination

• Mammogram history

• Axillary tenderness

Respiratory System

Assess:

• Cough

• Sputum production

• Hemoptysis

• Dyspnea

• Wheezing

• Chest pain

• Lung disease history

• Environmental exposures

• Chest X-ray

• Tuberculosis testing

Cardiovascular System

Assess:

• Chest pain

• Palpitations

• Orthopnea

• Peripheral edema

• Cyanosis

• Hypertension

• Coronary artery disease

• Heart murmurs

Gastrointestinal System

Assess:

• Appetite changes

• Dysphagia

• Heartburn

• Nausea

• Vomiting

• Abdominal pain

• Constipation

• Diarrhea

• Rectal bleeding

• Food intolerance

Genitourinary System

Assess:

• Urinary frequency

• Dysuria

• Hematuria

• Nocturia

• Urgency

• Incontinence

Additional assessment should include gender-specific reproductive history when appropriate.

Peripheral Vascular System

Assess:

• Claudication

• Cold extremities

• Varicose veins

• Blood clots

• Numbness

• Ulcers

Musculoskeletal System

Assess:

• Joint pain

• Muscle pain

• Muscle cramps

• Arthritis

• Gout

• Range of motion limitations

Neurological System

Assess:

• Syncope

• Seizures

• Weakness

• Stroke history

• Tremors

• Memory problems

• Mood changes

• Coordination

Hematologic System

Assess:

• Anemia

• Easy bruising

• Bleeding disorders

• Blood transfusions

• Enlarged lymph nodes

• Toxic exposures

Endocrine System

Assess:

• Heat intolerance

• Cold intolerance

• Excessive sweating

• Polyuria

• Polydipsia

• Polyphagia

• Diabetes

• Thyroid disease

• Hormone replacement therapy

Psychiatric System

Assess:

• Anxiety

• Depression

• Memory changes

• Mood disorders

• Previous psychiatric illness

• Suicide attempts

Organizing the Assessment

After completing the subjective interview and physical examination, formulate your clinical assessment.

List:

1. Primary diagnosis

2. Differential diagnosis

3. Rule-in diagnosis

4. Rule-out diagnosis

Each diagnosis should be supported by the patient’s history, physical findings, and available evidence.

Developing the Plan of Care

The treatment plan should include:

• Recommended diagnostic testing

• Medication management

• Patient education

• Lifestyle modifications

• Follow-up recommendations

• Appropriate referrals

Every intervention should directly address the patient’s diagnosis and overall health needs.

Example SOAP Note

Subjective

Chief Complaint

“I have had an itchy, scaly rash on my scalp and knees for two weeks. The rash has spread to my face, and I avoid going outside because I feel people are staring at me. I have also been unable to sleep, eat, or concentrate.”

History of Present Illness

A 30-year-old White female presents with a two-week history of an intensely pruritic, scaly rash affecting both knees and the scalp. She reports previous episodes of similar rashes, although they were less severe and did not involve the scalp. The current flare has significantly affected her sleep, appetite, concentration, and social interactions. She reports isolating herself after work because of embarrassment regarding the visible skin lesions.

Past Medical History

• Hypertension

• Allergic rhinitis

• Total hysterectomy for uterine fibroids

Current Medications

• Lisinopril 20 mg daily

• Loratadine 10 mg daily

Allergies

• No known drug allergies (NKDA)

Family History

• Mother: Hypertension

• Brother: Hypertension

Social History

The patient lives with her husband and two children and works as a bank teller. She denies tobacco use, alcohol consumption, recreational drug use, and any history of abuse.

Review of Systems

Skin: Reports scaly plaques on the scalp and knees. Denies changes in hair, nails, or moles.

Psychological: Reports poor sleep, decreased appetite, impaired concentration, and emotional distress related to the appearance of the rash.

Objective

General Appearance

Alert, oriented, well-groomed female in no acute distress.

Vital Signs

• Blood Pressure: 128/72 mmHg

• Heart Rate: 70 bpm

• Respiratory Rate: 18 breaths/min

• Temperature: 98.7°F

• Height: 5 ft 7 in

• Weight: 168 lb

Physical Examination

• Skin: Warm, dry skin with silvery plaques on the bilateral knees and frontal scalp.

• HEENT: Pale, boggy nasal mucosa with postnasal drainage.

• Respiratory: Regular, unlabored respirations with mild end-expiratory wheezing.

• Cardiovascular: Regular rate and rhythm without murmurs.

• Neurological: Alert and oriented ×4 with intact cranial nerves II–XII.

Assessment

Primary Diagnosis

Psoriasis, supported by recurrent silvery plaques involving the scalp and knees.

Differential Diagnoses

• Adjustment disorder with depressed mood secondary to chronic skin disease

• Allergic rhinitis

Plan

Diagnostic Evaluation

• Skin biopsy if diagnosis remains uncertain

• Complete blood count (CBC)

• Erythrocyte sedimentation rate (ESR)

• C-reactive protein (CRP)

• Vitamin D level

Treatment

• High-potency topical corticosteroid (e.g., clobetasol)

• Vitamin D analogue (e.g., calcipotriol)

• Daily emollient therapy

• Hydroxyzine for pruritus and sleep disturbance

• Intranasal corticosteroid and antihistamine for allergic rhinitis

Lifestyle Recommendations

Educate the patient about psoriasis triggers, stress reduction techniques, and maintaining a gentle skincare routine to minimize flare-ups.

Follow-Up

Schedule a follow-up visit within two to four weeks to evaluate treatment response. Consider systemic therapy or referral to dermatology if symptoms persist or worsen.

Key Takeaways

A thorough subjective health assessment combines accurate patient history, a structured HPI using the OLD CARTS framework, comprehensive past medical and family histories, lifestyle assessment, and a complete Review of Systems. Organizing these findings into a SOAP note supports clinical reasoning, evidence-based decision-making, and effective patient-centered care.

Frequently Asked Questions

What is the purpose of the subjective health assessment?

The subjective health assessment gathers information directly from the patient regarding symptoms, medical history, lifestyle, and personal concerns. This information guides diagnosis, physical examination, and treatment planning.

What does OLD CARTS stand for?

OLD CARTS is a clinical framework used to assess symptoms:

• O: Onset

• L: Location

• D: Duration

• C: Characteristics

• A: Aggravating or alleviating factors

• R: Radiation

• T: Timing

• S: Severity

Why is the Review of Systems important?

The Review of Systems helps identify symptoms affecting multiple body systems, uncovers previously unreported health concerns, and supports the development of accurate differential diagnoses.

What should be included in a SOAP note?

A SOAP note includes four sections:

• Subjective findings

• Objective findings

• Assessment

• Plan of care

This format promotes organized clinical documentation and continuity of patient care.

Why are differential diagnoses included in the assessment?

Differential diagnoses help clinicians compare potential conditions based on the patient’s symptoms and examination findings, ensuring appropriate diagnostic testing and evidence-based management.

Accurate subjective documentation is essential for advanced nursing practice because it establishes the foundation for clinical reasoning, guides physical examination priorities, supports differential diagnosis development, and informs patient-centered treatment decisions. Consistent use of structured frameworks such as OLD CARTS, comprehensive health histories, and SOAP documentation improves communication, documentation quality, and continuity of care across healthcare settings.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier. https://www.us.elsevierhealth.com/

Jarvis, C. (2024). Physical examination and health assessment (10th ed.). Elsevier. https://evolve.elsevier.com/

Bickley, L. S. (2025). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer. https://shop.lww.com/

NU552 Unit 2 Documenting Subjective information

American Academy of Dermatology Association. (2024). Psoriasis: Diagnosis and treatment. https://www.aad.org/public/diseases/psoriasis

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). https://www.psychiatry.org/psychiatrists/practice/dsm