Description
Hi everyone! Students will practice their interviewing skills for the lab component this week. Below are the documents you will be working with. Students may pair up with an adult-aged family member, friend, classmate, etc., to address the “S”oap part of the interview. Take as many notes as possible because then you will need to type up your “S”oap note and turn it in by the due date on the course calendar.
Your “patient” must be an adult, and it must be a volunteer. DO NOT USE REAL PATIENTS.
This assignment is to be a healthy check-up. Your patient’s chief complaint for this module should say: “Annual check-up.”
The HPI is never left blank.
In this module, we are practicing our interviewing techniques in the NP role and only taking a subjective history.
What do I mean by the “S” in SOAP? This is the subjective part of the note. It is never objective. Below is a table I created for you to help you along in the review of systems (ROS). Because this is a well-check examination, students will need to address at least three symptoms for each body system by either saying “complains” or “denies.” Points will be deducted if students document physical exam findings or medical terminology in the ROS. For example:
Respiratory: denies cough, shortness of breath, wheezing
What do you think about this neuro statement below?
Neuro: denies dizziness, syncope, numbness
Dizziness would be acceptable in the ROS but not in the physical exam because you can’t see dizziness, right?
Syncope is a medical term that most patients would not say, but you could say, “The patient denies passing out.”
Numbness is acceptable in the ROS, but it is incomplete in this case. The denies numbness? Numbness of what? Try to be as thorough as possible.
Below, you will find the template and a couple of more references on “How-tos” for writing a SOAP note.
Remember, we will not be doing any component of the physical exam in this module.
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Review of System Guide
Review of Systems
Constitutional/General
Circle Positives / Strikeout Negatives
Activity change, appetite change, chills, night
sweats, fatigue, fever, unexpected changes in
weight, body aches
Integumentary
Rash, birthmarks, wounds, itching, lesion,
hair loss, changes in nails, color changes,
dryness, pallor
Head
Head injury, trauma, scalp lesions
Eyes
Eye discharge, eye itching, eye pain, eye
redness, light sensitivity, visual disturbances
ENT
Congestion, dental problems, mouth sores,
bleeding gums, loose teeth, facial pain, dry
mouth, grinding teeth, drooling, ear discharge,
ear pain, facial swelling, hearing loss, mouth
sores, nosebleeds, postnasal drip, runny/stuffy
nose, sinus pain, sinus pressure, sneezing,
sore throat, ringing in the ears, trouble
swallowing, voice changes
Neck
Lumps, swollen glands, neck pain, neck
stiffness
Respiratory
Apnea, chest tightness, choking, cough, SOB,
wheezing, cough (productive or nonproductive), coughing up blood
Cardiovascular
Chest pain, leg swelling, racing heart, leg
cramps, pain in legs w/walking, SOB while
lying flat, SOB that wakes you up, heart
skipping
Gastrointestinal
Abdominal distention, abdominal pain,
constipation, diarrhea, nausea, vomiting,
heartburn
Rectum
Anal bleeding, blood in stool, hemorrhoids,
painful bowel movements, rectal pain
Genitourinary
Difficulty urinating, burning with urination,
flank pain, urinary frequency, bloody urine,
urinary urgency, urinary flow decreased,
incontinence
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Review of System Guide
Female GU
Painful sex, genital sores/lesions, menstrual
problems, pelvic pain, vaginal bleeding,
vaginal discharge, vaginal pain, hot flashes,
LMP
Male GU
Genital sores/lesions, erectile dysfunction,
caliber of urinary stream, hesitancy, dribbling,
penile discharge, masses in scrotum or
testicles, pain in scrotum or testicles
Breasts
Lumps, pain, changes in nipple appearance,
nipple discharge, changes in breast tissue
appearance: dimpling, redness, retracted
nipple, etc.
Musculoskeletal
Joint aches, back pain, body aches, difficulty
walking, joint swelling, neck pain, neck
stiffness, joint deformities
Neurological
Dizziness, facial asymmetry, headaches,
lightheadedness, numbness, uncontrollable
body movements, tremors, speech difficulty,
loss of consciousness, weakness, tingling,
tremors, involuntary movements
Endocrine
Heat intolerance, cold intolerance, excessive
sweating, excessive thirst, excessive hunger,
excessive urination
Hematologic/Lymphatic
Bruising, bruises easily, bleeds easily
Psychiatric
Agitation, behavior problems, confusion,
decreased confusion, hallucinations,
hyperactive, nervousness, anxious,
depression, self-injury, sleep disturbances,
memory changes, suicidal ideation (past
attempts), homicidal ideation
Do not ask all of these! They are here just as examples!
Guide to the Comprehensive Adult H&P Write‐Up
Chief Complaint
Include the primary symptom causing the patient to seek care. Ideally, this should be in the
patient’s words.
Source & Reliability
If the patient is not the source of the information state who is and if the patient is not
considered reliable explain why (e.g., “somnolent” or “intoxicated”)
History of Present
Illness
First sentence should include patient’s identifying data, including age, gender, (and race if
clinically relevant), and pertinent past medical history
Describe how chief complaint developed in a chronologic and organized manner
Address why the patient is seeking attention at this time
Include the dimensions of the chief complaint, including location, quality or character, quantity
or severity, timing (onset, duration and frequency), setting in which symptoms occur,
aggravating and alleviating factors and associated symptoms
Include the patient’s thoughts and feelings about the illness
Incorporate elements of the PMH, FH and SH relevant to the patient’s story.
Include pertinent positives and negative based on relevant portions of the ROS. If included in
the HPI these elements should not be repeated in the ROS
The HPI should present the context for the differential diagnosis in the assessment section
Past Medical History
Describe medical conditions with additional details such as date of onset, associated
hospitalizations, complications and if relevant, treatments
Surgical history with dates, indications and types of operations
OB/Gyn history with obstetric history (G,P – number of pregnancies, number of live births,
number of living children), menstrual history, birth control
Psychiatric history with dates, diagnoses, hospitalizations and treatments
Age‐appropriate health maintenance (e.g., pap smears, mammograms, cholesterol testing, colon
cancer) and immunizations
Describe any significant childhood illnesses
Medications
For each medication include dose, route, frequency and generic name
Include over the counter medications and supplements; include dose, route and frequency
Do not use abbreviations
Allergies
Describe the nature of the adverse reaction
Family history
Comment on the health state or cause of death of parents, siblings, children
Record the presence of diseases that run in the family (e.g., HTN, CAD, CVA, DM, cancer, alcohol
addiction)
Social history
Include occupation, highest level of education, home situation and significant others
Quantify any tobacco, alcohol or other drug use
Include relevant sexual history
Note any safety concerns by the patient (domestic violence, neglect)
Note presence of advance directives (e.g., living will and/or health care power of attorney)
Assess the patient’s functional status – ability to complete the activities of daily living
Consider documentation of any important life experience such as military service, religious
affiliation and spiritual beliefs
Review of Systems
Include patient’s Yes or No responses to all questions asked by system
Note “Refer to HPI” if question responses are documented in the HPI
Review of Systems:
Include in a bulleted format the pertinent review of systems questions that you asked. Below is an
example of thorough list. In a focused history and physical, this exhaustive list needn’t be included.
skin bruising, discoloration, pruritus, birthmarks, moles, ulcers, decubiti, changes in the hair or
nails, sun exposure and protection.
hematopoietic spontaneous or excessive bleeding, fatigue, enlarged or tender lymph nodes,
pallor, history of anemia.
head and face pain, traumatic injury, ptosis.
ears tinnitus, change in hearing, running or discharge from the ears, deafness, dizziness.
eyes change in vision, pain, inflammation, infections, double vision, scotomata, blurring, tearing.
mouth and throat dental problems, hoarseness, dysphagia, bleeding gums, sore throat, ulcers or
sores in the mouth.
nose and sinuses discharge, epistaxis, sinus pain, obstruction.
breasts pain, change in contour or skin color, lumps, discharge from the nipple.
respiratory tract cough, sputum, change in sputum, night sweats, nocturnal dyspnea, wheezing.
cardiovascular system chest pain, dyspnea, palpitations, weakness, intolerance of exercise,
varicosities, swelling of extremities, known murmur, hypertension, asystole.
gastrointestinal system nausea, vomiting, diarrhea, constipation, quality of appetite, change in
appetite, dysphagia, gas, heartburn, melena, change in bowel habits, use of laxatives or other
drugs to alter the function of the gastrointestinal tract.
urinary tract dysuria, change in color of urine, change in frequency of urination, pain with
urgency, incontinence, edema, retention, nocturia.
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genital tract (female) menstrual history, obstetric history, contraceptive use, discharge, pain or
discomfort, pruritus, history of venereal disease, sexual history.
genital tract (male) penile discharge, pain or discomfort, pruritus, skin lesions, hematuria,
history of venereal disease, sexual history.
skeletal system heat; redness; swelling; limitation of function; deformity; crepitation: pain in a
joint or an extremity, the neck, or the back, especially with movement.
nervous system dizziness, tremor, ataxia, difficulty in speaking, change in speech, paresthesia,
loss of sensation, seizures, syncope, changes in memory.
endocrine system tremor, palpitations, intolerance of heat or cold, polyuria, polydipsia,
polyphagia, diaphoresis, exophthalmos, goiter.
psychologic status nervousness, instability, depression, phobia, sexual disturbances, criminal
behavior, insomnia, night terrors, mania, memory loss, perseveration, disorientation
Physical examination
Describe what you see, avoid vague descriptions such as “normal”; The PE that relates to the
chief complaint may need to be MORE detailed than the sample below; record any “advanced”
findings/lack of findings that are pertinent (for example, presence or absence of egophany,
shifting dullness, HJR)
Physical Examination:
Always begin with the vital signs. These should include;
o Temperature
o Pulse
o Blood pressure
o Respiratory rate
o Pain (10‐point scale rating)
Pulse oximetry when available: include the percentage of supplemental O2. If room air,
document this.
EXAMPLE:
O2 Saturation: 88% on room air, 95% on 2 liter nasal canula.
General appearance: include information on the patient’s overall condition. It is appropriate to
comment on level of comfort or distress, as well as general grooming and hygiene.
Example:
•
•
Mr. Smith is a well appearing elderly gentleman in no acute distress.
Mr. Smith is a frail appearing elderly gentleman in significant
respiratory distress at the time of examination.
Next should follow the individual body systems in discreet subheadings.
Traditionally, systems are listed in a top down fashion when performing a full physical
examination. This may vary in subspecialty examinations such as ophthalmology or
orthopedics.
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In general, the format should be as follows
HEENT:
Neck:
Heart:
Lungs:
Abdomen:
Extremities:
Neurological:
MSK
Vascular:
Skin:
Example:
HEENT:
Head: no evidence of trauma
Nares: normal pink mucosa, no discharge
Eyes: no scleral icterus, normal conjunctiva
Ears: TM’s show normal light reflex, no erythema, normal
l landmarks
OP: moist mucus membranes; OP with no erythema or exudate. Oral exam with no lesions.
Neck: Supple, No thyromegaly, no lymphadenopathy, normal range of motion; JVP estimated to
be 7 cm.
Heart: PMI nondisplaced and normal size; No thrills or heaves; RRR, S1S2 with no s3 or s4, no
murmurs, rubs or gallops
Lungs: No increase work of breathing, lungs clear to auscultation, no wheezes or crackles
Abdomen: Non distended, no scars, normoactive bowel sounds, no bruits, non‐tender to
palpation, no hepatosplenomegaly, no masses
Exteremities: No clubbing, cyanosis or edema;
Vascular: pulses are 2+ bilaterally at carotid, radial, femoral, dorsalis pedis and posterior tibial;
no bruits
Neuro: alert and oriented x 3 (person, place and time), CN II‐XII intact; Motor 5/5 in all
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extremities. Reflexes 3+ and equal throughout. Sensory testing normal to light touch, pinprick,
proprioception, and vibration. Finger‐nose and Heel to shin/point to point testing normal.
Rapid alternating movements normal; Gait: normal get up and go, normal heel‐toe and tandem
gait
MSK: good tone throughout, no swelling/synovitis or limitation of flexion at any joint
Skin: normal texture, normal turgor, warm, dry, no rash
Data collection
Include lab and radiological data appropriate for the HPI (include YOUR interpretation, not just
copy/paste from medical record report)
Labs:
Chest xray or other xrays/scans
EKG:
Problem List
List all problems, most important first; You will use this to then begin to combine/lump
problems to then create your Assessment/Plan by problem list
For example:
Problem list:
Chest pain
Fever
Shortness of breath
Hemoptysis
Elevated creatinine
Summary Statement
Label as summary (“ In summary….)
Include 1‐2 sentence impression restating basic identifying information (The patient is a 45
year old male),
Most pertinent information related to the medical/family/social history (with a history of
tobacco use and family history of early CAD),
Expanded chief complaint and most pertinent review of systems on presentation (who
presents with substernal chest pressure, nausea and diaphoresis)
Most important findings on physical, labs, data (and is found to have an S4, bilateral rales,
and JVD on exam with evidence of pulmonary edema on CXR)
Pertinent information is that which contributes directly to building the case for your
differential diagnosis….
In summary, the patient is a 45 year old male with a history of tobacco use and family
history of early CAD who presents with substernal chest pressure, nausea and diaphoresis
and is found to have an S4, bilateral rales, and JVD on exam with evidence of pulmonary
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edema on CXR…
Key phrases and structure for summary statement:
In summary, this is a …
With a history of…
Who presents with….
And is found to have…
Assessment/Plan
Organize plan by problem: Label, Assessment/Plan by problem list
Include at least 3 diagnoses for your differential potentially associated with the patient’s
chief complaint
Include the Most Likely diagnosis/diagnoses on your differential
Include the DO NOT MISS diagnoses on your differential
Order your differential to reflect most likely diagnoses or most serious diagnoses first
For each diagnosis discuss physiologic disease basis relevant to the patient and elements from
the patient’s history and physical that either support or refute the diagnosis. For each item on
your differential, explain what makes it likely AND what makes it less likely.
It is OK to include less likely items on your differential – explain why it is important to consider
but less likely the diagnosis (PE may be considered frequently when a patient presents with
shortness of breath and should be on the differential because it is a Do Not Miss diagnosis – but if
the patient has a high white count, cough with sputum and infiltrate on exam, it is LESS likely)
For each problem, discuss the diagnostic plan, treatment plan and patient education.
Outline of what this should look like…
Summary Statement…
A/P by Problem List:
1. Problem # 1:
Differential Dx includes…. List at least 3 items for your differential, explain what
is most likely and why, what is a must not miss, and what is less likely and why….
Diagnostic Plan will be…
Treatment plan will include…
Patient education…. Instructions to patient include…
2. Problem # 2:
Differential….
Diagnostic Plan…
Treatment plan…
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Patient education
3. Problem # 3:
Differential…
Diagnostic plan…
Treatment plan…
Patient education…
For the main problem(s) identified in your problem list, you are expected to identify a topic or
clinical question that would help you advance your knowledge in that specific area to help you
provide better care of patients presenting in a similar way in the future. The topic or clinical
question can focus on an epidemiologic, diagnostic, therapeutic, pharmacologic, etc. aspect of
patient care.
In order to review the topic/answer your question, you should: 1) perform a literature or
textbook review to answer your clinical question, 2) incorporate your findings into the
assessment and plan of your write‐up in the form of 1‐2 paragraphs and 3) list the resources
used.
COM Library resources are strongly encouraged, for suitable resources based on topic of
interest please see P2 LibGuide.
Format
Goal is a concise write up with your thought processes documented in logical and organized
manner
Avoid spelling or grammatical errors
Use only commonly accepted abbreviations
HIPAA
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Remove patient identification from write up (e.g., name, address, medical record number, etc.)
NURS 756 Health History Interview Module 1 Template
CHIEF COMPLAINT
•
HISTORY OF PRESENT ILLNESS
•
REVIEW OF SYSTEMS
• Constitutional:
• Eyes:
• ENT:
• Neck/lymph:
• Cardiovascular:
• Respiratory:
• Gastrointestinal:
• Genitourinary:
• Musculoskeletal:
• Integumentary:
• Endocrine:
• Hematological:
• Neurologic:
• Psychiatric:
PAST MEDICAL HISTORY
• Past Medical History (bullet point)
SURGICAL HISTORY
• Surgical History (bullet point)
CURRENT MEDICATIONS
• Dosage, frequency, reason (bullet point)
• Immunizations
ALLERGIES
• Bullet point allergies and reaction
FAMILY HISTORY
• Bullet point history
SOCIAL HISTORY
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NURS 756 Health History Interview Module 1 Template
•
Bullet point history
SCREENINGS
• Bullet point screenings and your interpretation of the findings.
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NURS 756 Health History Interview Module 1 Template
PMP Instructions
Chief Complaint – brief statement of the patient’s own words. This is the reason why the patient
is coming to see you and is the only part of the charge allowed to be in quotations. Example:
“My throat hurts.”
History of Present Illness – this is a detailed interview prompted by the chief complaint or
presenting symptom. It is written in narrative (paragraph) form and is subjective. Since this is
subjective information, and it is written in words that a patient would say. For example, most
patients would say dizziness rather than vertigo. It should be in logical order. Many providers
use a system to help them remain consistent in their interview questions, such as OLDCARTS.
Using a system every time helps you not miss important information. You then need to add any
pertinent positives or negatives.
•
•
Example: XX is an 18-year-old female with a 3-day complaint of sore throat. She
describes it as a burning sensation that has been constant since the onset. It worsens with
swallowing, and rates it a 9/10. She has taken Tylenol, which hasn’t helped. Her last dose
was at 0800. She denies body aches, fevers, chills, headache, ear pain, runny/stuffy nose,
cough, shortness of breath, facial/chest congestion, abdominal pain, N/V, or unusual skin
rash. THE HPI NEEDS TO BE AS THOROUGH AS POSSIBLE. Points will be
deducted if medical terminology is used in the HPI.
The HPI can never be left blank even if you are evaluating a patient for a “healthy
check-up.”
Review of Systems – the ROS is comprehensive or focused depending on why the patient is
coming to see you. You would document a focused visit minimally in
constitutional/HENT/CVD/Respiratory/GI/Skin for the above patient. For the PMP assignment,
students are to state if a patient “DENIES” or “COMPLAINS OF” a minimum of 3 points in each
system. Using statements such as “all review of systems are negative unless noted in the HPI” or
using terms such as “negative for” or “positive for” will not be accepted. Points will be deducted
if medical terminology is used in the ROS. For an annual visit, sports physical, work physical,
establishing new care, routine healthy check-up, etc. you will need to ask about all systems.
Past Medical History – this is the total sum of a patient’s health status before the presenting
problem. Birth history if less than 5 years of age. This area of the chart is bullet-pointed.
Surgical History – this is the total sum of a patient’s surgical history. This area of the chart is
bullet-pointed.
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NURS 756 Health History Interview Module 1 Template
Current Medications – include dosing, frequency, and reason for all prescriptions, OTCs,
CAMs, etc. Pertinent immunization history goes in this section of the chart. This area of the chart
is bullet-pointed.
Allergies – includes medication and foods, and reaction. This area of the chart is bullet-pointed.
Family History –family history helps risk-stratify patients with conditions and genetic links. It
provides information to the provider for early warning signs of disease. Anticipatory guidance
can be developed from the family history. Family history includes 1st, 2nd, and 3rd generation
relatives. Students need to add the age of all relatives (age at the time of death for the deceased)
and any presence of chronic diseases. This area of the chart is bullet-pointed.
Social History – broad category of the patient’s medical history that includes smoking, vaping,
other tobacco use, alcohol, drug use, relationship status, occupation, hobbies, developmental,
school, work, 24O hour diet recall, and sexual activity (including the number of partners and
male/female/or both). This area of the chart is bullet-pointed.
Screenings – pertinent screenings are next. Examples of screenings include hearing, vision,
developmental, GAD, depression, etc. List any screenings here that you performed with this
patient. You will need to state why you performed any screenings. For example, did you request
a GAD because the patient is complaining of anxiety, or is it part of their annual exam?
Revised 1/2023
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