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Purdue University Globle
NU552 Advanced Health Assessment Course Module Overview
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Date
A well-written SOAP note provides a structured way to document a patient encounter, organize clinical findings, support diagnostic reasoning, and develop an evidence-based plan of care. For advanced health assessment coursework, a complete SOAP note should clearly separate subjective information reported by the patient from objective findings obtained through examination and testing. It should also demonstrate clinical reasoning by identifying a working diagnosis, considering appropriate differential diagnoses, and outlining a patient-specific treatment and follow-up plan.
The SOAP note should begin with essential patient information while protecting privacy and confidentiality. In an academic or clinical setting, use the patient’s initials rather than a full name unless institutional documentation requirements specify otherwise.
Relevant demographic information may include:
Date of the history and interview
Patient initials
Age and date of birth
Gender
Race and ethnicity
Primary language
Place of birth
Marital or relationship status
Cultural background
Highest level of education
Occupation
Health insurance or coverage type
Source of the history and its reliability
The source of the history is particularly important when information is obtained from a family member, caregiver, interpreter, or another healthcare professional rather than directly from the patient.
The chief complaint (CC) identifies the primary reason the patient is seeking healthcare. Whenever possible, document the complaint using the patient’s own words and include the duration of the problem.
Examples include:
“I’ve had chest pain for two hours.”
“I have been coughing for one week.”
“I get short of breath when I walk.”
The chief complaint should be concise. Detailed symptom information belongs in the History of Present Illness.
The History of Present Illness (HPI) provides a chronological description of the patient’s current health concern. A strong HPI explains when the problem started, how it has progressed, what symptoms are present, and what factors make the condition better or worse.
One commonly used approach for organizing the HPI is the OLD CARTS framework:
Onset: When did the symptom begin?
Location: Where is the symptom located?
Duration: How long has it been present?
Character: How does the symptom feel or present?
Aggravating or alleviating factors: What makes it worse or better?
Radiation: Does the symptom move or spread to another area?
Timing: Is it constant, intermittent, or associated with specific events?
Setting: What was happening when the symptom began?
Rather than presenting OLD CARTS as a disconnected checklist, incorporate the findings into a chronological narrative. This approach makes the patient’s clinical story easier to understand and demonstrates organized clinical reasoning.
The Past Medical History (PMH) provides background information that may influence the patient’s current condition, risk factors, diagnosis, and treatment.
Document significant current and previous medical conditions, including chronic diseases, major injuries, hospitalizations, disabilities, and other clinically important events.
Examples include hypertension, diabetes, asthma, cardiovascular disease, kidney disease, previous infections, major trauma, and other chronic or acute conditions.
When relevant, document significant childhood illnesses and infections, including:
Measles
Mumps
Rubella
Chickenpox
Pertussis
Streptococcal infections
Record previous surgical procedures and, when known, include the date and whether the procedure was performed on an inpatient or outpatient basis.
Previous surgical history can be clinically significant because it may affect current symptoms, anatomy, medication use, and future treatment decisions.
For patients for whom this information is clinically relevant, document pregnancy and reproductive history. This may include gravida, term births, preterm births, abortions, and living children.
Additional information may include menstrual history, menopausal status, pregnancy complications, and relevant gynecologic conditions.
Review immunization status according to the patient’s age, health conditions, occupation, risk factors, and current recommendations.
Relevant vaccines may include:
Routine childhood vaccines
Influenza vaccination
Pneumococcal vaccination
Herpes zoster vaccination
COVID-19 vaccination
Other indicated adult immunizations
Document relevant mental health conditions, previous psychiatric treatment, counseling, medication use, psychiatric hospitalization, and other behavioral health concerns.
Mental health history should be documented objectively and respectfully.
Record allergies to medications, foods, environmental substances, latex, and other known allergens.
For each allergy, document the patient’s reaction when known. For example, simply documenting “penicillin allergy” provides less clinical information than documenting “penicillin—rash and facial swelling.”
Medication reconciliation should include all substances the patient currently uses, including:
Prescription medications
Over-the-counter medications
Vitamins
Herbal products
Dietary supplements
When available, include the medication name, dose, route, frequency, and reason for use. Accurate medication documentation helps identify potential interactions, duplications, contraindications, and adherence concerns.
Health maintenance documentation addresses preventive care appropriate for the patient’s age, sex, health status, and risk factors.
This may include routine examinations, cancer screening, immunizations, laboratory screening, cardiovascular risk assessment, and other preventive services.
Family history helps identify inherited conditions and familial patterns of disease. Document relevant health information for immediate and, when appropriate, extended family members.
Important family conditions may include:
Hypertension
Diabetes
Coronary artery disease
Stroke
Cancer
Kidney disease
Arthritis
Mental health conditions
Other hereditary disorders
Record whether significant family members are living or deceased and include the cause of death when clinically relevant.
A focused family history is particularly useful when evaluating conditions with a strong genetic or familial component.
The Personal and Social History evaluates behavioral, environmental, occupational, cultural, and lifestyle factors that may influence health outcomes.
Areas commonly addressed include living arrangements, activities of daily living, occupation, education, relationships, sexual health, tobacco use, alcohol consumption, recreational drug use, nutrition, physical activity, and spiritual or religious considerations when relevant to care.
Sexual history should be obtained in a professional, nonjudgmental manner and should address clinically relevant factors such as sexual practices, partners, contraception, sexually transmitted infection risks, and reproductive goals.
Social history can also identify barriers to care, including transportation problems, financial concerns, food insecurity, housing instability, limited social support, or difficulty accessing medications.
The Review of Systems (ROS) is a systematic assessment of symptoms organized by body system. It helps identify symptoms that may not have been discussed during the HPI and allows clinicians to document relevant positive and negative findings.
Assess for changes in:
Weight
Energy level
Strength
Appetite
Temperature or fever
Fatigue
Ask about rashes, lesions, itching, dryness, changes in hair or nails, new or changing moles, and other skin abnormalities.
Assess for headaches, dizziness, lightheadedness, syncope-related symptoms, and previous head injuries.
Document vision changes, eye pain, redness, blurred or double vision, corrective lens use, cataracts, glaucoma, and other visual concerns.
Assess hearing loss, tinnitus, vertigo, ear pain, infections, and ear drainage.
Evaluate congestion, rhinorrhea, nosebleeds, allergic symptoms, sinus infections, and changes in smell when clinically relevant.
Assess oral health, dental problems, bleeding gums, dentures, dry mouth, difficulty swallowing, sore throat, hoarseness, and tongue abnormalities.
Assess for neck pain or stiffness, lymph node enlargement, thyroid enlargement, and other neck abnormalities.
When clinically appropriate, ask about breast masses, pain, skin changes, nipple changes, and nipple discharge.
Assess for cough, sputum production, shortness of breath, wheezing, hemoptysis, and pleuritic chest pain.
Document symptoms such as chest pain, palpitations, exertional symptoms, edema, and relevant cardiovascular history.
Assess for:
Abdominal pain
Nausea and vomiting
Heartburn
Difficulty swallowing
Appetite changes
Constipation
Diarrhea
Rectal bleeding
Food intolerance
Excessive gas
Liver or gallbladder problems
Assess urinary frequency, urgency, dysuria, hematuria, polyuria, nocturia, flank pain, kidney stones, and urinary incontinence.
For male patients, additional urinary concerns may include changes in urinary stream, hesitancy, or incomplete bladder emptying.
For male patients, relevant concerns may include testicular pain, scrotal swelling, penile lesions, hernias, and sexually transmitted infections.
For female patients, assessment may include menstrual history, menopausal symptoms, abnormal bleeding, vaginal discharge, pelvic pain, and dyspareunia.
Assess for claudication, cold extremities, swelling, varicose veins, skin discoloration, ulcers, numbness, and previous blood clots.
Assess joint and muscle pain, stiffness, arthritis, gout, weakness, mobility limitations, range of motion, and spinal problems.
Assess for headaches, syncope, seizures, weakness, paralysis, tremors, sensory changes, memory problems, coordination difficulties, and previous stroke.
Assess for anemia, unusual bruising, abnormal bleeding, blood transfusions, lymph node enlargement, and relevant exposure history.
Evaluate symptoms associated with endocrine dysfunction, including heat or cold intolerance, excessive sweating, increased thirst, increased hunger, and increased urination.
Assess mood, anxiety, depression, memory, behavioral changes, suicidal thoughts, previous suicide attempts, and other relevant mental health concerns.
Any positive response should be explored further when clinically appropriate.
The Objective section contains information obtained through direct observation, physical examination, vital signs, diagnostic testing, and other measurable findings.
Objective findings should be specific rather than vague. For example, instead of documenting “lungs normal,” describe the relevant examination findings, such as clear breath sounds bilaterally without wheezes, crackles, or rhonchi when those findings are actually observed.
Document the patient’s general appearance, level of distress, hygiene, body habitus, posture, mobility, and apparent level of consciousness.
Mental status and overall behavior may also be documented when relevant.
Record appropriate vital signs and measurements, including:
Blood pressure
Heart rate
Respiratory rate
Temperature
Oxygen saturation
Height
Weight
Body mass index
Interpret vital signs in the context of the patient’s age, health status, symptoms, medications, and clinical presentation.
Assess skin color, temperature, moisture, texture, turgor, lesions, wounds, rashes, and other relevant abnormalities.
Perform and document appropriate examination of the head, eyes, ears, nose, oral cavity, and throat.
Findings should be specific and should reflect the examination actually performed.
Evaluate the thyroid, cervical lymph nodes, tracheal position, range of motion, and other relevant structures.
A complete respiratory examination generally includes inspection, palpation, percussion, and auscultation.
Document relevant findings such as:
Chest expansion
Tactile fremitus
Percussion characteristics
Diaphragmatic excursion when assessed
Breath sounds
Adventitious sounds
Voice transmission findings
Assess the cardiovascular system systematically. Depending on the clinical situation, this may include evaluation of the carotid arteries, jugular venous pressure, precordium, point of maximal impulse, heart sounds, murmurs, extra heart sounds, thrills, heaves, and peripheral pulses.
When indicated, document inspection and palpation findings, including symmetry, skin changes, nipple characteristics, tenderness, masses, and discharge.
Assess the axilla for skin abnormalities, lymph node enlargement, tenderness, and mobility of palpable nodes.
Document abdominal findings based on inspection, auscultation, percussion, and palpation.
Relevant findings may include abdominal contour, bowel sounds, tenderness, guarding, rebound, masses, organ enlargement, and other abnormalities when assessed.
Assess posture, gait, joint range of motion, muscle strength, mobility, and other findings relevant to the patient’s complaint.
Document relevant neurologic findings, which may include mental status, cranial nerves, motor function, sensation, reflexes, coordination, gait, balance, and other neurologic assessments.
The Assessment section brings together the subjective and objective findings and explains their clinical significance. This is where the healthcare professional demonstrates diagnostic reasoning.
The assessment should identify the most likely working diagnosis and explain the findings that support it. Appropriate differential diagnoses should also be considered when more than one condition could reasonably explain the patient’s presentation.
A useful assessment generally includes:
Primary or working diagnosis
Clinical evidence supporting the diagnosis
Relevant abnormal findings
Pertinent positive and negative findings
Differential diagnoses
Clinical reasoning behind the diagnostic impression
The working diagnosis should generally be presented first, followed by relevant differential diagnoses.
The Plan section explains how the patient’s condition will be evaluated and managed. The plan should be individualized and supported by current evidence and applicable clinical guidelines.
Depending on the patient’s presentation, the plan may include:
Diagnostic laboratory or imaging studies
Prescription or nonprescription medications
Nonpharmacologic interventions
Lifestyle recommendations
Patient education
Preventive care
Follow-up timing
Specialist referrals
Warning signs requiring urgent or emergency evaluation
Each intervention should have a clear relationship to the patient’s assessment and identified clinical needs.
Patient education should be specific and understandable. The plan should also address medication adherence, potential adverse effects, self-management strategies, and when the patient should seek additional care when applicable.
An effective SOAP note is organized, clinically relevant, specific, and easy for another healthcare professional to understand. It should distinguish subjective information from objective findings while connecting those findings to the assessment and plan.
A strong SOAP note should:
Follow a logical clinical sequence.
Separate subjective and objective information.
Document pertinent positive and negative findings.
Use appropriate medical terminology.
Demonstrate clinical reasoning.
Support the working diagnosis with clinical evidence.
Address reasonable differential diagnoses.
Provide an individualized and evidence-based plan.
Document patient education and follow-up.
Protect patient privacy and confidentiality.
Avoid copying irrelevant information into every section. Documentation should be comprehensive enough to support clinical decision-making while remaining focused on the patient’s current needs.
SOAP documentation provides a standardized method for organizing information collected during a patient encounter. By separating subjective complaints from objective findings and connecting both to assessment and treatment planning, the format promotes clearer clinical communication and continuity of care.
For graduate-level nursing students and advanced practice learners, SOAP note writing is also an opportunity to demonstrate more than documentation skills. A well-developed note shows the ability to collect a focused history, perform an appropriate physical examination, interpret clinical findings, develop differential diagnoses, and select evidence-based interventions.
Accurate documentation can also contribute to patient safety by making important clinical information available to other members of the healthcare team.
SOAP stands for Subjective, Objective, Assessment, and Plan. The four sections organize information reported by the patient, findings obtained through examination or testing, clinical interpretation of those findings, and the proposed management plan.
The History of Present Illness should provide a chronological description of the patient’s current problem. OLD CARTS can help organize information about onset, location, duration, character, aggravating or alleviating factors, radiation, timing, and setting.
Subjective data is information reported by the patient or another source, such as symptoms, concerns, medical history, or pain descriptions. Objective data consists of information that can be observed or measured, including vital signs, physical examination findings, laboratory results, imaging findings, and clinical observations.
Differential diagnoses demonstrate clinical reasoning. They identify other conditions that could explain the patient’s symptoms and show that alternative explanations were considered before selecting the most likely working diagnosis.
The Assessment section should summarize the clinical interpretation of the patient’s presentation. It generally includes the working diagnosis, supporting evidence, pertinent findings, and relevant differential diagnoses.
The Plan may include diagnostic testing, medications, nonpharmacologic treatment, patient education, preventive care, referrals, and follow-up instructions. The interventions should correspond to the patient’s assessment and clinical needs.
Students can improve SOAP notes by using a consistent structure, documenting specific findings, distinguishing subjective from objective information, supporting diagnoses with clinical evidence, considering differential diagnoses, and developing a clear evidence-based plan. Reviewing current clinical guidelines and instructor or program documentation requirements can also improve accuracy.
An advanced health assessment SOAP note is more than a checklist of patient information. It is a structured clinical record that connects the patient’s history and symptoms with physical examination findings, diagnostic reasoning, and an individualized plan of care. By documenting subjective and objective data accurately and explaining the reasoning behind the assessment and plan, nursing students can demonstrate professional documentation skills and stronger clinical judgment.
For advanced health assessment assignments, the most effective approach is to keep the documentation organized, clinically relevant, patient-centered, and supported by current evidence. Consistent SOAP note practice can strengthen both academic performance and the documentation skills needed for professional nursing practice.
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