NU552 Unit 4 Advanced Health Assessment SOAP Note Template

Student Name

Purdue University Globle 

NU552 Advanced Health Assessment and Diagnostic Reasoning

Prof. Name

Date

Advanced Health Assessment SOAP Note Medical Documentation 

A comprehensive SOAP note is a structured clinical document used to record patient encounters accurately and support safe, evidence-based decision-making. In the MN552 Advanced Health Assessment Unit 4 assignment, students must document subjective and objective findings, formulate differential diagnoses, identify a working diagnosis, and develop an appropriate treatment plan. Completing each section thoroughly ensures accurate clinical reasoning and professional medical documentation.

Initial Patient Information

Begin the SOAP note by recording the patient’s identifying and demographic information. Maintain patient confidentiality by using initials instead of the full name.

Include the following:

• Date of history/interview

• Source of history and reliability

• Patient initials

• Primary language

• Age and date of birth

• Place of birth

• Gender

• Race

• Marital status

• Ethnic or cultural background

• Highest education completed

• Occupation or profession

• Health insurance type (commercial, state, or federal)

Chief Complaint (CC)

The chief complaint documents the patient’s primary reason for seeking healthcare. Record the complaint using the patient’s own words whenever possible.

Examples include:

• “Chest pain for two hours.”

• “Persistent cough for one week.”

• “Shortness of breath while walking.”

The statement should clearly identify the primary symptom and indicate when it began.

History of Present Illness (HPI)

The History of Present Illness is a chronological narrative describing the patient’s current health concern from symptom onset to the present visit.

Document the HPI using the OLD CARTS framework:

• Onset: When did the symptom begin?

• Location: Where is the symptom located?

• Duration: How long has it lasted?

• Character: What does the symptom feel like?

• Aggravating or Alleviating Factors: What worsens or relieves it?

• Radiation: Does the symptom spread elsewhere?

• Timing: Is it constant or intermittent?

• Setting: Under what circumstances did it occur?

Rather than listing each category separately, incorporate all findings into a clear, organized paragraph that tells the patient’s story.

Past Medical History (PMH)

A complete medical history provides essential background for clinical decision-making.

Medical History

Document significant medical conditions throughout the patient’s lifespan, including:

• Chronic illnesses

• Major injuries

• Previous hospitalizations

• Blood transfusions

• Permanent disabilities

Childhood Illnesses

Include a history of common childhood diseases, such as:

• Measles

• Mumps

• Rubella

• Chickenpox

• Pertussis

• Streptococcal infections

Surgical History

Record:

• Surgical procedures

• Dates

• Inpatient or outpatient status

Obstetric History

When applicable, document:

• Number of pregnancies

• Term births

• Preterm births

• Abortions (spontaneous or induced)

• Living children

Immunization History

Include all relevant vaccinations, including:

• Childhood immunizations

• Pneumococcal vaccine

• Herpes zoster vaccine

• Influenza vaccine

• COVID-19 vaccination, if applicable

Psychiatric History

Document:

• Childhood psychiatric conditions

• Adult mental health diagnoses

• Previous psychiatric treatment or hospitalization

Allergies

Identify allergies to:

• Medications

• Foods

• Environmental allergens

• Other substances

Describe the patient’s reaction to each allergen.

Current Medications

Include every medication the patient currently uses:

• Prescription medications

• Over-the-counter drugs

• Herbal products

• Dietary supplements

Record dosage, route, frequency, and indication when available.

Health Maintenance

Document preventive healthcare measures, including:

• Annual physical examinations

• Cancer screenings

• Vaccination status

• Routine laboratory testing

• Age-appropriate preventive services

Family History

Family history helps identify hereditary disease risks.

Document the health status of:

• Parents

• Siblings

• Grandparents

• Children

• Spouse, when clinically relevant

Include significant conditions such as:

• Hypertension

• Diabetes

• Heart disease

• Stroke

• Arthritis

• Cancer

• Kidney disease

• Mental illness

Also indicate whether each family member is living or deceased.

Personal and Social History

A comprehensive social history evaluates environmental, behavioral, and lifestyle factors affecting health.

Document information regarding:

• Activities of daily living (ADLs)

• Living arrangements

• Occupation

• Educational background

• Sexual orientation

• Gender identity

• Sexual practices

• Relationship status

• Tobacco use

• Alcohol consumption

• Recreational or illicit drug use

• Nutrition

• Exercise habits

• Spiritual or religious beliefs

• Lifestyle habits

Review of Systems (ROS)

The Review of Systems systematically identifies symptoms across body systems. Record both pertinent positives and pertinent negatives.

General

Assess:

• Weight changes

• Fatigue

• Weakness

• Fever

Skin

Evaluate:

• Rashes

• Lesions

• Pruritus

• Dryness

• Hair changes

• Nail abnormalities

• Mole changes

HEENT

Head

Assess for:

• Headache

• Dizziness

• Head injury

• Lightheadedness

Eyes

Document:

• Vision changes

• Corrective lenses

• Eye pain

• Redness

• Blurred or double vision

• Cataracts

• Glaucoma

Ears

Assess:

• Hearing loss

• Tinnitus

• Vertigo

• Ear pain

• Ear discharge

Nose and Sinuses

Evaluate:

• Nasal congestion

• Rhinorrhea

• Epistaxis

• Allergic rhinitis

• Sinus infections

Mouth and Throat

Assess:

• Oral health

• Bleeding gums

• Denture use

• Dry mouth

• Hoarseness

• Sore throat

• Tongue abnormalities

Neck

Assess for:

• Lymph node enlargement

• Goiter

• Neck pain

• Neck stiffness

Breasts

Document:

• Breast lumps

• Pain

• Nipple discharge

Respiratory

Evaluate:

• Cough

• Sputum production

• Hemoptysis

• Dyspnea

• Wheezing

• Pleuritic chest pain

Cardiovascular

Assess:

• Chest pain

• Palpitations

• Hypertension

• Murmurs

• Rheumatic fever history

• Peripheral edema

Gastrointestinal

Document:

• Dysphagia

• Heartburn

• Appetite changes

• Nausea

• Vomiting

• Constipation

• Diarrhea

• Rectal bleeding

• Abdominal pain

• Food intolerance

• Excessive gas

• Liver or gallbladder disease

Urinary

Assess:

• Urinary frequency

• Urgency

• Dysuria

• Hematuria

• Polyuria

• Nocturia

• Flank pain

• Kidney stones

• Incontinence

Male patients should also be assessed for urinary stream abnormalities.

Genital

For male patients, document:

• Hernias

• Penile lesions

• Testicular pain

• Scrotal swelling

• Sexually transmitted infections

For female patients, assess:

• Menstrual history

• Menopausal symptoms

• Postmenopausal bleeding

• Vaginal discharge

• Dyspareunia

Peripheral Vascular

Evaluate:

• Claudication

• Cold extremities

• Numbness

• Varicose veins

• Blood clot history

• Skin discoloration

• Ulcers

Musculoskeletal

Assess:

• Joint pain

• Muscle pain

• Joint stiffness

• Arthritis

• Gout

• Range of motion limitations

• Spinal disorders

Neurologic

Document:

• Syncope

• Seizures

• Weakness

• Paralysis

• Stroke history

• Tremors

• Sensory deficits

• Memory changes

• Coordination problems

Hematologic

Assess for:

• Anemia

• Easy bruising

• Bleeding disorders

• Blood transfusions

• Enlarged lymph nodes

• Radiation exposure

• Toxic chemical exposure

Endocrine

Evaluate:

• Heat intolerance

• Cold intolerance

• Excessive sweating

• Increased thirst

• Increased hunger

• Increased urination

Psychiatric

Assess:

• Anxiety

• Depression

• Mood changes

• Memory impairment

• Suicidal thoughts

• Suicide attempts

• Behavioral concerns

Objective Physical Examination

The objective section documents measurable findings obtained during the physical examination.

General Survey

Record the patient’s:

• Overall appearance

• Level of distress

• Hygiene

• Mental status

Vital Signs

Include:

• Blood pressure

• Heart rate

• Respiratory rate

• Temperature

• Oxygen saturation

• Height

• Weight

• Body mass index (BMI)

Skin

Assess:

• Color

• Moisture

• Temperature

• Lesions

• Turgor

HEENT

Document inspection and examination findings for the:

• Head

• Eyes

• Ears

• Nose

• Throat

Neck

Evaluate:

• Thyroid

• Cervical lymph nodes

• Range of motion

• Tracheal alignment

Respiratory Examination

Assess the lungs using standard examination techniques:

• Inspection

• Palpation

• Percussion

• Auscultation

Document:

• Chest expansion

• Tactile fremitus

• Percussion notes

• Diaphragmatic excursion

• Breath sounds

• Adventitious sounds

• Voice transmission findings

Cardiovascular Examination

Evaluate:

• Carotid arteries

• Jugular venous pressure

• Precordial inspection

• Point of maximal impulse

• Heart sounds (S1 and S2)

• Murmurs

• Extra heart sounds

• Thrills

• Heaves

• Peripheral pulses

Breast Examination

Document:

• Inspection

• Symmetry

• Skin changes

• Nipple characteristics

• Palpation findings

• Tenderness

• Masses

• Discharge

Axillary Examination

Assess:

• Skin condition

• Lymph nodes

• Tenderness

• Mobility

Abdomen

Document findings from:

• Inspection

• Auscultation

• Percussion

• Palpation

Musculoskeletal

Assess:

• Joint mobility

• Muscle strength

• Gait

• Posture

Neurologic Examination

Evaluate:

• Cranial nerves

• Motor function

• Sensory function

• Reflexes

• Coordination

• Balance

• Mental status

Assessment

The assessment summarizes clinical findings and diagnostic reasoning.

Include:

• Primary (working) diagnosis

• Supporting clinical evidence

• Differential diagnoses considered

List the working diagnosis first, followed by alternative diagnoses that were evaluated during clinical decision-making.

Plan of Care

Develop an evidence-based management plan tailored to the patient’s condition.

The plan should include:

1. Diagnostic testing

2. Medications

3. Non-pharmacologic interventions

4. Patient education

5. Follow-up recommendations

6. Referrals to specialists when indicated

Ensure each intervention aligns with the working diagnosis and current clinical practice guidelines.

Key Components of an Effective SOAP Note

A high-quality SOAP note should:

• Present information in a logical sequence.

• Clearly distinguish subjective from objective findings.

• Include pertinent positive and negative findings.

• Demonstrate sound clinical reasoning.

• Support the diagnosis with assessment findings.

• Provide an evidence-based treatment plan.

• Maintain professional medical terminology and documentation standards.

Why Is the SOAP Note Format Important?

The SOAP note is widely used in nursing and healthcare because it promotes standardized documentation, improves communication among healthcare professionals, and supports continuity of patient care. For advanced practice nursing students, mastering SOAP note documentation also strengthens diagnostic reasoning, clinical assessment skills, and evidence-based treatment planning.

Frequently Asked Questions

What does SOAP stand for in nursing documentation?

SOAP stands for Subjective, Objective, Assessment, and Plan. This structured documentation method organizes patient information into a standardized clinical format that supports accurate diagnosis and continuity of care.

What should be included in the History of Present Illness (HPI)?

The HPI should describe the patient’s current health concern chronologically using the OLD CARTS framework: onset, location, duration, character, aggravating or alleviating factors, radiation, timing, and setting.

What is the difference between subjective and objective data?

Subjective data consists of information reported by the patient, including symptoms, medical history, and concerns. Objective data includes measurable findings obtained through physical examination, vital signs, diagnostic tests, and clinical observations.

Why are differential diagnoses included in a SOAP note?

Differential diagnoses demonstrate clinical reasoning by identifying alternative conditions that may explain the patient’s symptoms before confirming the final working diagnosis.

What is included in the treatment plan?

The treatment plan typically includes diagnostic testing, medications, patient education, lifestyle recommendations, follow-up appointments, referrals, and any additional interventions needed to manage the patient’s condition.

Accurate SOAP note documentation improves communication among healthcare providers, supports evidence-based clinical decisions, enhances patient safety, and serves as a legal record of the patient encounter. Comprehensive documentation also demonstrates advanced assessment skills and professional competency expected in graduate-level nursing practice.

References

American Association of Nurse Practitioners. (2024). Standards of practice for nurse practitioners. https://www.aanp.org/practice/practice-related/standards-of-practice

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/

Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer. https://shop.lww.com/Bates–Guide-to-Physical-Examination-and-History-Taking/p/9781975210877

NU552 Unit 4 Advanced Health Assessment SOAP Note Template

Centers for Disease Control and Prevention. (2024). Adult immunization schedule by age. https://www.cdc.gov/vaccines/schedules/

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier. https://evolve.elsevier.com/

Sullivan, D. D. (2023). Guide to clinical documentation (4th ed.). F.A. Davis. https://www.fadavis.com/