Using SOAP Notes to Document a Focused Health History and Physical Assessment

Using SOAP Notes to Document a Focused Health History and Physical Assessment Objective Document assessment findings according to the accepted documentation styles Discussion Overview In this discussion forum, you will review the case scenario of a nurse conducting a focused health history interview and assessment. You will be asked to consider which components of the case will be recorded using a problem-oriented documentation style. Deliverables Your participation in the discussion forum, including the following: A response to the initial questions below Responses to at least two other students’ posts Step 1 Review the case scenario. You are working in the free clinic as a nurse. As a part of your role, you conduct the initial history and assessment prior to having the client see the physician or advanced practice nurse who is on call. You walk into the exam room where Mrs. Taylor is waiting to be seen. You introduce yourself and complete the initial focused history and physical assessment. During the interview, you gather the following information: Mrs. Taylor states, “I woke up this morning and my right eye was pink, swollen, burning, and itchy. I had to use a wash cloth to get my eyelids to come apart because they were crusted with some drainage. The drainage went away after I washed my eye but keeps coming back.” During the physical assessment, you gather the following information: Upon examining Mrs. Taylor’s eyes, the left eye was within normal limits. The right eye was red, watery, and had small amounts of purulent drainage. You are now ready to document your findings and develop a plan of care for Mrs. Taylor using a SOAP note format style.