Medical diagnosis plan

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

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.