Differentiating Components of Health Assessment.

Differentiating Components of Health Assessment.

Please review the following data and differentiate subjective, objective, assessment and plan data.  Place the data under the appropriate component of the assessment and Submit the completed chart.

  1. Bilateral Breath sounds clear to auscultation
  2. Consumes 75% of meals
  3. Pneumonia
  4. Fine Needle Aspiration of thyroid gland
  5. Refer to Pulmonology
  6. Chronic Bronchitis
  7. “My throat is sore and I’m hoarse”
  8. Hemoglobin 25
  9. Sister with breast cancer
  10. Relieve of chest pain with Tylenol
  11. Back pain score 8/10 with radiation to legs
  12. Skin warm and dry
  13. “My head hurts”
  14. Potassium 3.8
  15. Refer to Oncology
  16. COPD
  17. Left mastitis
  18. Lateral curvature of thoracic spine
  19. Productive cough x 10 days of green yellow sputum
  20. Chest pain associated with activity
Subjective DataObjective DataAssessment (medical diagnosis)Plan (orders)
    
    
    
    
    
    
    
    
    
    

Differentiating Components of Health Assessment

Subjective DataObjective DataAssessment (medical diagnosis)Plan (orders)
“My throat is sore and  hoarse”PneumoniaBilateral Breath sounds clear to auscultationRefer to Pulmonology
Chest pain associated with activityChronic BronchitisProductive cough x 10 days of green yellow sputumRelieve of chest pain with Tylenol
My head hurts”Hemoglobin 25Lateral curvature of thoracic spineFine Needle Aspiration of thyroid gland
Sister with breast cancerPotassium 3.8Left mastitis  Refer to Oncology
Back pain score 8/10 with radiation to legsCOPDSkin 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.

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.

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