MN552 Unit 3 -Assignment

Unit 3: Introduction to Physical Exam, General Survey, Vital Signs, Skin, and HEENT

SOAP Note Section II: Lifestyle Pattern and ROS

This section of the SOAP note will include history of lifestyle patterns and the review of systems (ROS).

1. Document appropriate data in      the relevant body system. 
   1. Do not state “Negative, NA or       Unremarkable” for any systems because the reader will not know which       questions were actually asked by the provider.
2. This is a comprehensive health      history and should not contain physical exam findings. The focused history      data is relevant to the chief complaint and identified by pertinent      positive data documented during the health history.
3. Address each component of the      SOAP note as noted in the written guide with relevant data.
4. You may continue with the same      volunteer to complete each section of the SOAP note.