Comprehensive Subjective Data

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  • Identify a friend peer or family member you can interview.
  • Collect information to construct a complete and comprehensive subjective data set consistent with documentation requirements for a new patient scheduled for an annual wellness exam.
  • Conduct an interview.
  • Document your findings on the provided SOAP note template. Structure the subjective data set on the SOAP note template in the format provided in your lecture materials.

Submit the Word file containing your subjective data set on the SOAP note template to this

comprehensive subjective data

Step 1: Identify an Interviewee

  • Choose a friend, peer, or family member to interview. Ensure that they are comfortable with sharing their health-related information for this educational exercise. Let them know that their information will be kept confidential and used solely for the purpose of this assignment.

Step 2: Conducting the Interview

Use open-ended questions to gather comprehensive subjective data. Here’s a general structure you can follow to guide your interview:

  1. Chief Complaint (CC): Ask the interviewee if they have any specific concerns or reasons for the wellness exam. For example: “Are you experiencing any health issues or concerns lately?”
  2. History of Present Illness (HPI): If they have any complaints, gather detailed information about the onset, duration, location, severity, and any associated symptoms. Example questions: “When did you first notice the issue? Is it getting worse or better?”
  3. Past Medical History (PMH): Ask about any previous health conditions, hospitalizations, or surgeries. Inquire about chronic conditions like diabetes or hypertension. Example: “Have you been diagnosed with any medical conditions in the past?”
  4. Family History (FH): Collect information on the interviewee’s family health background, particularly focusing on hereditary conditions such as heart disease, cancer, or mental health issues.
  5. Social History (SH): Ask about lifestyle habits such as smoking, alcohol use, recreational drug use, occupation, and living environment. Example: “Do you smoke or consume alcohol? How often?”
  6. Medications: Ask about current medications, including over-the-counter drugs, supplements, and herbal remedies. Example: “Are you currently taking any medications or supplements?”
  7. Allergies: Document any known allergies, including reactions to medications, food, or environmental factors.
  8. Review of Systems (ROS): Conduct a head-to-toe review by asking about symptoms in each body system (e.g., respiratory, cardiovascular, gastrointestinal). This step helps to identify any underlying issues that may not have been previously mentioned.

Step 3: Documenting the Subjective Data on a SOAP Note

A SOAP note is divided into four sections, but for this assignment, you will focus on Subjective data. This includes the patient’s personal account of their symptoms and medical history.

Here’s an example of how to structure the subjective section using a SOAP note format:

Subjective

  • Chief Complaint (CC): “I’m here for my annual wellness exam. No major complaints, but I have been feeling a bit more fatigued recently.”
  • History of Present Illness (HPI): The patient reports mild fatigue that started about three weeks ago. It is most noticeable in the evenings and does not interfere with daily activities. No associated symptoms like chest pain, shortness of breath, or dizziness. No recent illnesses or infections. The patient denies any recent changes in weight, appetite, or sleep patterns.
  • Past Medical History (PMH):
    • Hypertension diagnosed five years ago, managed with medication.
    • Appendectomy at age 25.
    • Denies history of diabetes, asthma, or heart disease.
  • Family History (FH):
    • Father: Diagnosed with type 2 diabetes at age 55.
    • Mother: Hypertension.
    • No known family history of cancer or mental health issues.
  • Social History (SH):
    • Smokes 1-2 cigarettes daily for the past 10 years.
    • Social alcohol use: about 2-3 drinks per week.
    • Works as a teacher; moderate stress levels due to workload.
    • Exercises three times a week (jogging and yoga).
    • Denies any recreational drug use.
  • Medications:
    • Lisinopril 10 mg once daily for hypertension.
    • Multivitamin daily.
    • No use of herbal supplements.
  • Allergies:
    • No known drug allergies.
    • Mild seasonal allergies (pollen), managed with antihistamines.
  • Review of Systems (ROS):
    • General: Reports feeling more fatigued recently but no fever, chills, or weight loss.
    • Cardiovascular: No chest pain, palpitations, or edema.
    • Respiratory: No shortness of breath, cough, or wheezing.
    • Gastrointestinal: No nausea, vomiting, abdominal pain, or changes in bowel habits.
    • Musculoskeletal: Reports occasional lower back pain, especially after long periods of standing. Denies joint pain or stiffness.

Step 4: Submitting the SOAP Note Template

After completing the interview and filling out the subjective section, save the file as a Word document and ensure the format aligns with the template provided in your lecture materials. Review your notes for completeness and clarity before submitting.

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