Name
Purdue University Globle
NU552 Advanced Health Assessment Course Module Overview
Prof. Name
Date
Accurate subjective documentation begins with a systematic health history interview that captures the patient’s concerns, symptoms, medical history, family history, lifestyle factors, and Review of Systems (ROS). For an advanced health assessment, these findings should be organized clearly and objectively before being combined with physical examination findings in a SOAP note. Using structured approaches such as OLD CARTS for the History of Present Illness (HPI) and a comprehensive ROS helps clinicians recognize clinically important information, support differential diagnoses, communicate effectively with other healthcare professionals, and develop an appropriate plan of care.
When documenting a health history, use the patient’s own words when appropriate, distinguish subjective information from objective findings, avoid unnecessary assumptions, and protect the patient’s privacy by using only the information required for the assignment.
The subjective portion of a health assessment consists of information obtained directly from the patient or another appropriate source during the health history interview. Unlike objective findings, which are observed or measured by the clinician, subjective information describes what the patient experiences, reports, or believes about their health.
A well-conducted subjective assessment provides the foundation for clinical reasoning. The clinician should establish rapport, use therapeutic communication, listen actively, ask appropriate follow-up questions, and clarify information that is incomplete or unclear.
For an academic health assessment assignment, a volunteer family member or friend may be interviewed when permitted by the course instructions. Do not include unnecessary identifying information, such as a full name, address, telephone number, or other protected health information.
Begin the health history by documenting the date of the interview, the source of the information, and the reliability of the historian.
For example:
Source: Patient
Reliability: Patient appears to be a reliable historian.
If information is obtained from another person, identify the relationship to the patient and indicate why that source was used.
Biographical information establishes the demographic and social context needed for an individualized health assessment. Depending on the assignment and clinical setting, relevant information may include:
Patient initials rather than a full name
Age and date of birth
Preferred language
Sex and gender identity, when clinically relevant
Race and ethnicity, when relevant to the assessment
Place of birth
Marital or relationship status
Cultural background
Highest level of education
Occupation
Health insurance or healthcare coverage
Demographic information should be collected respectfully and should have a clear clinical or assessment purpose. Cultural, language, educational, and socioeconomic factors can affect communication, access to healthcare, health behaviors, and treatment planning.
The chief complaint (CC) identifies the primary concern that brought the patient to healthcare. Whenever possible, document the complaint using the patient’s own words and place it in quotation marks.
A chief complaint should generally be concise and should communicate the primary symptom or reason for the visit.
Example:
“I’ve had chest pain for the past two hours.”
The chief complaint should not contain an extensive interpretation or diagnosis. Those details belong in the HPI and assessment.
The History of Present Illness (HPI) provides a detailed, chronological description of the patient’s current problem. It expands on the chief complaint by explaining when the symptom began, how it has changed, what makes it better or worse, and how it affects the patient’s daily life.
One commonly used framework for organizing symptom information is OLD CARTS.
| Component | What to Assess |
|---|---|
| O – Onset | When did the symptom begin? Was the onset sudden or gradual? |
| L – Location | Where is the symptom located? |
| D – Duration | How long does each episode last, and how long has the problem been present? |
| C – Characteristics | What does the symptom feel, look, or sound like? |
| A – Aggravating/Alleviating Factors | What makes the symptom better or worse? |
| R – Radiation | Does the symptom move or spread to another area? |
| T – Timing | How often does the symptom occur? Is there a particular pattern? |
| S – Severity | How severe is the symptom, usually on a 0–10 scale, and how does it affect functioning? |
The clinician should also explore the patient’s perspective. Questions such as the following can reveal the patient’s understanding, concerns, and expectations:
“What do you think is causing this problem?”
“What concerns you most about these symptoms?”
“What have you tried to make the symptoms better?”
The HPI should normally be documented as a coherent narrative rather than as a list of isolated answers.
The Past Medical History (PMH) identifies previous illnesses, procedures, hospitalizations, treatments, allergies, medications, and preventive care that may influence the patient’s current health.
Relevant information may include previous or current:
Medical conditions
Childhood illnesses
Surgical procedures and dates
Hospitalizations
Blood transfusions
Obstetric and gynecologic history, when applicable
Immunizations
Psychiatric or behavioral health history
Allergies and associated reactions
Prescription medications
Over-the-counter medications
Vitamins, supplements, and herbal products
Preventive screenings and health maintenance
Preventive health information may include age- and risk-appropriate examinations and screening tests, such as vision and dental examinations, cervical cancer screening, breast cancer screening, colorectal cancer screening, lipid testing, tuberculosis screening, and other recommended preventive services.
The specific screenings documented should reflect the patient’s age, sex, risk factors, history, and current clinical guidelines rather than assuming that every patient requires every test.
A family history (FHx) helps identify hereditary conditions, familial disease patterns, and health risks. Relevant family members may include parents, siblings, grandparents, children, and other relatives when appropriate.
For each relevant family member, document:
Relationship to the patient
Major chronic illnesses
Genetic or hereditary conditions
Significant psychiatric conditions, when relevant
Major causes of illness or death
Age and health status, when appropriate
Instead of simply documenting that a family member is deceased, provide the cause of death when it is known and clinically relevant.
Lifestyle and social factors can have a substantial effect on health outcomes. A comprehensive assessment should consider the patient’s environment, health behaviors, relationships, occupational exposures, and access to resources.
Areas that may be relevant include:
Dietary habits and nutrition
Fluid intake
Sleep patterns
Physical activity and exercise
Tobacco and nicotine use
Alcohol consumption
Recreational or illicit drug use
Occupational exposures
Living environment and safety
Activities of Daily Living (ADLs)
Instrumental Activities of Daily Living (IADLs)
Family and social relationships
Spiritual or religious beliefs
Cultural practices
Immigration and travel history
Stress and coping strategies
Sexual and reproductive health
Intimate partner violence and safety
Cognitive and functional status
Not every question is appropriate for every patient. The interview should be individualized and conducted in a respectful, nonjudgmental manner.
The Review of Systems (ROS) is a systematic inventory of symptoms organized by body system. It is based primarily on information reported by the patient and is separate from the objective physical examination.
A comprehensive ROS may include the following systems.
Assess for:
Fever or chills
Fatigue
Weakness
Unintentional weight loss or gain
Changes in appetite
General changes in health
Pertinent negative example:
Denies fever, fatigue, weakness, or recent unexplained weight change.
Pertinent positive example:
Reports an approximately 10-pound unintentional weight gain over the past two months accompanied by fatigue.
Assess for:
Rashes
Lesions
Itching
Dryness
Changes in skin color
Changes in hair
Changes in nails
New or changing moles
Assess for:
Headaches
Head injury
Dizziness
Vertigo
Loss of consciousness
Assess for:
Vision changes
Eye pain
Redness
Swelling
Blurred or double vision
Excessive tearing
Visual field changes
Use of corrective lenses
Most recent eye examination
Assess for:
Hearing loss
Tinnitus
Ear pain
Ear infections
Ear drainage
Hearing aid use
Changes in hearing
Assess for:
Nasal congestion
Nasal discharge
Allergies
Epistaxis
Sinus pressure or pain
Changes in the sense of smell
Assess for:
Dental problems
Gum bleeding
Oral ulcers
Dry mouth
Sore throat
Hoarseness
Difficulty swallowing
Denture use
Most recent dental examination
Assess for:
Neck pain
Stiffness
Swollen glands
Masses
Thyroid enlargement
Changes in range of motion
When applicable, assess for:
Breast pain
Breast masses or lumps
Nipple discharge
Skin changes
Previous breast conditions
Relevant breast imaging history
Axillary symptoms
Assess for:
Cough
Sputum production
Hemoptysis
Shortness of breath
Wheezing
Chest discomfort
Previous lung disease
Environmental or occupational exposures
Relevant tuberculosis or respiratory testing
Assess for:
Chest pain or pressure
Palpitations
Shortness of breath
Orthopnea
Paroxysmal nocturnal dyspnea
Peripheral edema
Cyanosis
Hypertension
Coronary artery disease
Heart murmurs
Previous cardiovascular disease
Assess for:
Appetite changes
Difficulty swallowing
Heartburn or reflux
Nausea
Vomiting
Abdominal pain
Constipation
Diarrhea
Changes in bowel habits
Rectal bleeding
Food intolerance
Assess for:
Urinary frequency
Dysuria
Hematuria
Nocturia
Urgency
Incontinence
Changes in urine
Reproductive or sexual health concerns when appropriate
Gender- and age-appropriate reproductive history should be included when clinically relevant.
Assess for:
Claudication
Cold extremities
Varicose veins
Edema
History of blood clots
Skin ulcers
Numbness or changes in circulation
Assess for:
Joint pain
Muscle pain
Muscle weakness
Muscle cramps
Arthritis
Gout
Joint swelling
Range-of-motion limitations
Assess for:
Headaches
Syncope
Seizures
Weakness
Numbness or tingling
Tremors
Stroke or transient ischemic attack history
Memory changes
Balance or coordination problems
Assess for:
Anemia
Easy bruising
Excessive bleeding
Blood disorders
Previous blood transfusions
Enlarged lymph nodes
Relevant toxic or occupational exposures
Assess for:
Heat intolerance
Cold intolerance
Excessive sweating
Increased thirst
Increased urination
Increased hunger
Diabetes
Thyroid disease
Hormonal disorders
Hormone replacement therapy
Assess for:
Anxiety
Depression
Mood changes
Sleep disturbances
Memory or concentration changes
Previous psychiatric conditions
Substance-use concerns
Suicidal thoughts or previous suicide attempts when clinically appropriate
Suicide and self-harm questions should be asked directly when indicated by the patient’s presentation or risk factors and should be handled according to clinical safety protocols.
A high-quality ROS should not simply list every possible symptom. Instead, it should identify findings that are relevant to the patient’s presenting concern and differential diagnosis.
Pertinent positives are symptoms the patient reports.
Pertinent negatives are clinically relevant symptoms the patient specifically denies.
For example, when evaluating a patient with respiratory symptoms, documentation might state:
Reports productive cough and intermittent wheezing. Denies hemoptysis, pleuritic chest pain, or recent travel.
This approach makes the documentation more clinically meaningful and easier for other healthcare professionals to interpret.
After completing the subjective history and objective examination, the clinician interprets the collected information and develops an assessment.
The assessment may include:
Primary or most likely diagnosis
Differential diagnoses
Conditions that should be ruled in
Conditions that should be ruled out
Relevant contributing factors or comorbidities
Clinical diagnoses should be supported by the patient’s history, physical examination, diagnostic findings, and current evidence. A diagnosis should not be assigned solely because a single symptom appears consistent with a particular condition.
The plan should directly address the patient’s identified problems and clinical priorities. Depending on the situation, the plan may include:
Diagnostic testing
Medication management
Nonpharmacologic treatment
Patient education
Lifestyle recommendations
Preventive care
Referrals
Safety or return precautions
Follow-up evaluation
Medication selection and diagnostic testing should be based on the patient’s individual history, contraindications, current guidelines, and clinical judgment.
A SOAP note organizes clinical information into four sections:
S – Subjective: Information reported by the patient or another source.
O – Objective: Measurable or observable findings, including vital signs, physical examination findings, and relevant test results.
A – Assessment: The clinician’s interpretation of the findings, including the primary diagnosis and appropriate differential diagnoses.
P – Plan: Diagnostic, therapeutic, educational, preventive, referral, and follow-up interventions.
Keeping these categories separate improves clarity and supports continuity of care.
The following example demonstrates how subjective and objective information can be organized into a SOAP note. In actual clinical practice, diagnoses and treatment decisions should be based on a complete evaluation and current clinical guidelines.
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 woman presents with a two-week history of an intensely pruritic, scaly rash involving both knees and the scalp, with reported extension to the face. She reports having experienced similar but less severe episodes in the past. The current flare has negatively affected her sleep, appetite, concentration, and social activities. She reports avoiding social interactions after work because she feels embarrassed by the visible skin lesions.
Past Medical History
Hypertension
Allergic rhinitis
History of total hysterectomy for uterine fibroids
Current Medications
Lisinopril 20 mg daily
Loratadine 10 mg daily
Allergies
No known drug allergies reported.
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, and recreational drug use. She denies a history of abuse.
Review of Systems
Skin: Reports pruritic, scaly plaques involving the scalp and knees. Denies changes in hair, nails, or moles.
Psychological: Reports poor sleep, decreased appetite, difficulty concentrating, and emotional distress associated with the appearance of the skin lesions.
General Appearance
Alert and oriented adult female who is well groomed and appears mildly distressed regarding her skin condition. No acute cardiopulmonary distress is observed.
Vital Signs
Blood pressure: 128/72 mmHg
Heart rate: 70 beats/minute
Respiratory rate: 18 breaths/minute
Temperature: 98.7°F
Height: 5 feet 7 inches
Weight: 168 pounds
Physical Examination
Skin: Warm and dry with well-demarcated, scaly plaques noted over the bilateral knees and frontal scalp.
HEENT: Pale, boggy nasal mucosa with postnasal drainage.
Respiratory: Respirations regular and unlabored. Mild end-expiratory wheezing noted.
Cardiovascular: Regular rate and rhythm without an audible murmur.
Neurological: Alert and oriented ×4. Cranial nerves II–XII grossly intact.
The distribution and appearance of recurrent scaly plaques involving the scalp and knees are consistent with a possible diagnosis of psoriasis. However, the diagnosis should be confirmed through the complete clinical assessment and consideration of other dermatologic conditions.
The patient’s sleep disturbance, appetite reduction, impaired concentration, and social withdrawal may represent psychological distress associated with the visible skin condition and should be assessed further rather than automatically assigning a psychiatric diagnosis.
The patient also has a history of allergic rhinitis, with examination findings that may be consistent with ongoing allergic symptoms.
Potential differential diagnoses may include:
Psoriasis
Seborrheic dermatitis
Atopic dermatitis or another eczematous disorder
Tinea or other dermatologic infection, depending on clinical appearance
Psychosocial distress associated with chronic or visible skin disease
Additional findings and diagnostic evaluation should guide the final diagnosis.
Diagnostic Evaluation
Additional evaluation should be guided by the clinical presentation. If the diagnosis is uncertain, dermatologic evaluation or biopsy may be considered. Laboratory testing should be ordered only when clinically indicated rather than as a routine requirement for every patient with suspected psoriasis.
Treatment and Symptom Management
For confirmed psoriasis, treatment may include appropriately selected topical therapies, moisturization, and other treatments based on disease severity and location. High-potency topical corticosteroids should be used carefully and according to appropriate prescribing guidance, particularly on sensitive areas such as the face.
Management of allergic rhinitis may include appropriate intranasal therapy and antihistamines when clinically indicated.
Patient Education
Educate the patient about psoriasis, potential triggers, adherence to prescribed treatment, gentle skin care, moisturization, and strategies for managing stress. Discuss the potential psychological effects of visible skin disease and encourage the patient to report worsening mood, social withdrawal, or safety concerns.
Follow-Up
Arrange follow-up to assess symptom improvement, treatment response, medication tolerance, and psychological well-being. Consider referral to dermatology when the diagnosis is uncertain, symptoms are extensive or difficult to control, or specialized treatment is indicated.
Accurate subjective documentation is an essential component of advanced nursing assessment. A detailed health history allows clinicians to understand the patient’s symptoms in context rather than viewing individual complaints in isolation.
A systematic interview can help the clinician:
Identify the patient’s primary concerns
Recognize important symptoms and risk factors
Establish an accurate timeline of illness
Identify relevant medical and family history
Recognize psychosocial and behavioral influences
Develop appropriate differential diagnoses
Determine priorities for the physical examination
Support evidence-based care planning
Improve communication and continuity of care
Using consistent documentation frameworks also makes clinical information easier for other members of the healthcare team to review.
A comprehensive subjective health assessment should begin with the patient’s chief concern and expand into a detailed HPI, past medical history, family history, social and lifestyle history, and Review of Systems.
The OLD CARTS framework can help organize symptom characteristics, while the SOAP format provides a structured method for documenting subjective findings, objective findings, clinical assessment, and the plan of care.
The most effective documentation is accurate, concise, patient-centered, clinically relevant, and supported by appropriate evidence. Patient privacy should also be protected throughout the interview and documentation process.
Subjective information is health information reported by the patient or another appropriate source. It includes symptoms, perceptions, concerns, medical history, lifestyle information, and other experiences that cannot be directly measured by the clinician.
Subjective data are reported by the patient, such as pain, nausea, fatigue, or dizziness. Objective data are observable or measurable findings, such as blood pressure, temperature, heart rate, physical examination findings, laboratory results, or imaging results.
OLD CARTS is a framework used to characterize symptoms:
O: Onset
L: Location
D: Duration
C: Characteristics
A: Aggravating and alleviating factors
R: Radiation
T: Timing
S: Severity
It helps clinicians collect a consistent and detailed HPI.
A comprehensive health history may include biographical information, chief complaint, HPI, past medical history, medications, allergies, immunizations, family history, social history, lifestyle factors, preventive health information, and Review of Systems.
The ROS provides a systematic inventory of symptoms by body system. It helps identify relevant positive and negative findings and can support clinical reasoning and differential diagnosis.
Pertinent positives are clinically relevant symptoms or findings that the patient reports. Pertinent negatives are relevant symptoms that the patient specifically denies. Both can help narrow the differential diagnosis.
SOAP stands for:
Subjective: Patient-reported information
Objective: Measurable or observable findings
Assessment: Clinical interpretation and diagnoses
Plan: Diagnostic, therapeutic, educational, referral, and follow-up actions
Differential diagnoses identify other conditions that could explain the patient’s presentation. Considering multiple possibilities helps clinicians determine which additional information, examinations, or tests may be necessary before establishing a final diagnosis.
The chief complaint should generally be brief and written using the patient’s own words whenever possible. For example:
“I’ve had a headache for three days.”
The detailed description of the symptom belongs in the HPI.
Health assessment documentation can contain sensitive personal and health information. Academic assignments should follow course instructions and privacy requirements, using de-identified information whenever possible and avoiding unnecessary identifying details.
American Academy of Dermatology Association. (n.d.). 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
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/9781975161153
Jarvis, C. (2024). Physical examination and health assessment (10th ed.). Elsevier. https://www.elsevier.com/books/physical-examination-and-health-assessment/jarvis/978-0-323-83356-4
National Institute of Mental Health. (n.d.). Suicide prevention. https://www.nimh.nih.gov/health/topics/suicide-prevention
U.S. Department of Health and Human Services. (n.d.). Physical activity guidelines for Americans. Office of Disease Prevention and Health Promotion. https://health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines
