Differentiating Components of Health Assessment
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Differentiating Components of Health Assessment
| Subjective Data | Objective Data | Assessment (medical diagnosis) | Plan (orders) |
| “My throat is sore and hoarse” | Pneumonia | Bilateral Breath sounds clear to auscultation | Refer to Pulmonology |
| Chest pain associated with activity | Chronic Bronchitis | Productive cough x 10 days of green yellow sputum | Relieve of chest pain with Tylenol |
| My head hurts” | Hemoglobin 25 | Lateral curvature of thoracic spine | Fine Needle Aspiration of thyroid gland |
| Sister with breast cancer | Potassium 3.8 | Left mastitis
|
Refer to Oncology |
| Back pain score 8/10 with radiation to legs | COPD | Skin warm and dry | |
| Consumes 75% of meals | |||
Short summary
Objective, subjective, health assessment and plan of action are all components of a SOAP note. SOAP note is a medical form which facilitates easy documentation process of the patient. Subjective data includes all information provided by the client regarding the health complication. It includes chief complaints and family, social and current medical histories (Reznich, Wagner, & Noel, 2010). The subjective data explains the patient’s condition using narrative form. It includes the onset of the condition, its chronology, quality of the pain, factors which modify the pain and associated symptoms. Objective data includes all traceable facts. It includes data from clinical laboratory reports and from other vital findings. This data will include physical assessment data such as age, weight etc. This data is straight forward and includes disease vital signs such as Blood Pressure, respiration, temperature etc. (Mitsuishi, Et al., 2014).
Health Assessment refers to a quick summary of objective and subjective information. It includes lists of potential diagnoses. In some cases, assessment will include diagnostic tests information such as X-rays, blood analysis among others. The problem list is numerically listed as supported by objective and subjective findings. This is the part which aids in developing of differential diagnosis. Plan (Orders) include all actions that will be conducted as guided by the assessment. They include specific laboratory duties; intention for hospitalization; study of specific diagnoses; differential diagnoses; medication therapy and follow up actions (Erickson, McKnight, & Utzman, 2008).
References
Erickson, M., McKnight, R., & Utzman, R. (2008). Physical therapy documentation. Thorofare, NJ: SLACK.
Mitsuishi, F., Young, J., Leary, M., Dilley, J., & Mangurian, C. (2014). The Systems SOAP Note: A Systems Learning Tool. Academic Psychiatry. doi:10.1007/s40596-014-0128-5. Retrieved from http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=12d28572-cabe-4aaf-b355-4d40fb3e2538%40sessionmgr4003&vid=0&hid=4205
Reznich, C., Wagner, D., & Noel, M. (2010). A repurposed tool: the Programme Evaluation SOAP Note. Medical Education, 44(3), 298-305. doi:10.1111/j.1365-2923.2009.03600.x. Retrieved http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=dfcf3206-e0fd-4e06-a590-6898a729ba23%40sessionmgr4002&vid=0&hid=4205
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