NURS612_SoapNote_PracticeActivity_Week2
docx
keyboard_arrow_up
School
Maryville University *
*We aren’t endorsed by this school
Course
612
Subject
Medicine
Date
Apr 3, 2024
Type
docx
Pages
2
Uploaded by ChancellorAtom11593
Soap Note Practice Activity-Week 2
Last week you developed your CC and HPI on the scenarios. This week you will focus on the in the information you will obtain in the PMH, SH, FH, and ROS. What medical information would you obtain in each of the sections of the SOAP note below? What questions would you ask?
PMH (Past medical history)
The past medical history includes general health over the patient’s lifetime and disabilities and functional limitations as the patient perceives them. Questions to be
asked include topics such as hospitalization and/or surgery, major childhood illnesses, major adult illnesses, serious injuries, immunizations, medications, allergies, transfusion, mental health, and recent laboratory tests.
FH (Family history)
This includes a pedigree with at least three generations; if a pedigree is not available, documentation includes a family history of major health or genetic disorders, spontaneous abortions, and stillbirths, including the age and health of spouse and children. Questions asked pertain to major health or genetic disorders in the family; this includes hypertension, cancer, cardiac, respiratory, kidney disease, stroke, thyroid disorder, blood dyscrasias, psychiatric illnesses, tuberculosis, rheumatic disease, diabetes mellitus, hepatitis, asthma, or other allergic manifestations.
SH (social history)
Information in this section varies according to the patient's concerns and the health
problem's influence on the patient’s life. Questions in this section arise from cultural background and practices, home environment, occupation, current health habits and/or risk factors, exposure to chemicals, military services, sexual activity, and concerns about cost of care/healthcare coverage. Consider the following patient scenarios, what ROS (review of systems) areas would you address? What questions would you ask for each of these patients?
Scenario 1 is an acute visit; your note should be focused. Focused on the areas that
are pertinent to why the patient came in.
Scenario 2
, the patient presents for a physical examination, no health concerns, you will develop a comprehensive ROS. Scenario 1
: Alex is a 40-year-old man with complaints of a sore throat. Areas that would be addressed in this acute visit include the Head, Neck, Eyes, Ears,
and Throat; these systems are pertinent to the patient to rule out/in upper respiratory infections. Questions asked in this section include duration/length of time with symptoms, aggravating factors, when symptoms started, current remedies for sore throat and their effectiveness.
Scenario 2
: Maria, 44-year-old female that, presents for a routine yearly physical examination.
This patient presented for an annual physical assessment with no health concerns; this physical examination will focus on a general assessment rather than a focused examination pertinent to the chief complaint. Questions in this area will focus on family history, social history, and past medical history.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help