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Basics of an Initial Patient Assessment

Instructor: Rachel Torrens

Rachel is a Nurse Practitioner with experience working as a high school teacher, skin surgery center, and as a family NP.

Assessing a patient may seem like an overwhelming assignment, but using the simple tool of a SOAP note makes it manageable. This lesson describes the format of a SOAP note and how it will help to guide your initial patient assessment.

SOAP Note as a Springboard

When you first meet a patient, the task of assessing their problem and assisting them may seem overwhelming. Where do you start? Well, there is a helpful format for documenting your assessment, called a SOAP note, which will simultaneously guide you through the patient's entire visit.

A SOAP note is a thorough, yet efficient, method of recording your encounter with a patient. The term 'SOAP' is an acronym for:

  • Subjective
  • Objective
  • Assessment
  • Plan

Let's take a closer look at each of these terms. When they are combined, an entire visit with a patient will be completed!

Subjective Portion of a SOAP Note

The subjective part of a patient assessment involves everything the patient wants to tell you from his or her perspective. How do you obtain their point of view of the problem? You simply ask. For example, you may begin by asking 'What is bothering you today?' The patient, who we'll call Mary, responds with 'I have a cold.'

Most likely, this is all a patient needs to begin telling their story to you. As the story progresses, you may need to ask more questions to further clarify the situation. For example, you may say 'I understand that you have a cold. When did it start? What symptoms are you experiencing? Have you tried anything to feel better?'

During the initial interview, the healthcare provider gleans all the subjective information from the patient.
Provider interviewing patient

All of the information obtained from the patient's storytelling is known as the 'subjective', or it may also be referred to as the 'history'. The subjective portion of an assessment is very important. It helps to guide the next step in the process, the objective exam.

Objective Portion of a SOAP Note

The objective portion of a patient assessment involves everything you can observe with your own eyes. More specifically, this part of the process involves a physical exam.

A good place to start is with vital signs, which include heart rate, respiratory rate, temperature, and blood pressure. This basic information can tell you a great deal about a patient's overall status. If all the vital signs are within normal limits, you can feel reassured that the patient is not in need of emergency care. You can now proceed to a regular exam.

The physical exam gives the provider objective information.
Provider performing an ear exam.

The physical exam you choose to perform should be based upon the patient's major problem. Let's return to our patient Mary. Since she is complaining of a cold, you will want to perform a physical exam that is specifically targeted towards her complaint. So, examining her ears, nose, throat, and also her lymphatic system would be wise.

Also, it is prudent to assess a patient's heart and lungs during any encounter. Since a beating heart and breathing lungs are essential for life, knowing that these are stable in your patient is considered critical, regardless of the presenting problem.

Assessment Portion of a SOAP Note

During the assessment you take all the information you've gleaned from the subjective and objective portions and use them to identify the problem. This may be referred to as a 'diagnosis' as well.

Let's return once more to our friend Mary. Based on the information gathered from the initial interview and the physical exam, you identify Mary's problem as sinusitis (a sinus infection). Identifying a patient's problem is quite a feat, so you should be very proud of yourself. But now, what are you going to do about it?

Plan Portion of a SOAP Note

The final portion of any patient encounter is formulating a plan of care. This section details what you plan to do to help alleviate the patient's problem. A plan of care may include medications, laboratory tests, imaging, or other medical tests. It may also include lifestyle modifications the patient needs to implement. Truly, a plan of care involves any piece of information you believe will help to solve the problem and prevent its recurrence.

Often, but not always, medications are part of a patient plan of care. Other interventions may include the ordering of tests or referral to a specialist.
Prescription medications

What should you do for Mary? Well, you most likely should prescribe an antibiotic and offer Mary an antihistamine to help with her symptoms until the antibiotic takes effect. Finally, you can encourage her to call if her symptoms do not improve.

Example of a Completed SOAP Note

The following is an example of what a completed SOAP note would look like. Do not worry if you do not understand all the medical abbreviations, which are covered in another lesson.

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