MN552 Advanced Health AssessmentUnit 3 SOAP Note Section II and III Written Guide1. Document appropriate data in the relevant body system.a. Do not state Negative, NA or Unremarkable for any systems because the readerwill 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 pertinentpositive data documented during the health history.3. Address each component of the SOAP note as noted in the written guide with relevantdata.4. You may continue with the same volunteer to complete each section of the SOAP note.II. Life style patternsa.b.c.d.e.f.g.h.i.j.Immigrant status: The patient is a U.S born citizenSpiritual resources/religion: QQ is a Catholic Christian.Health perception: At the age of 56, QQ appears healthy and strong.Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains orlosses; recall of usual intake; any cultural restrictions/intolerances; amount of fluidper day and type: no changes in appetite; loss of 2 kg in the last two months; takestwo liters of water and juice every dayElimination patterns: Bowel (usual pattern and characteristics); bladder (usual patternand characteristics); any incontinence: Usual bowel movements; urge urinaryincontinenceLiving environment: City, state; urban, rural, community; type of dwelling, faci ...
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