NUR 6001 Advanced Health Assessment Exam 1
Study Guide | Latest Actual verified study set
complete Solutions | 2026 Updates | 100% Pass
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Exam 1 Guide
- Components of health history and SOAP note documentation
- Skin – different lesions, their differential diagnoses and assessment findings
o Common geriatric skin lesions
o Skin Ca
- Eye exam – assessment techniques and findings
o Cranial nerves
- Ears – infection, hearing loss
- Nose/Mouth/Throat – assessment techniques and findings including thyroid and lymph
nodes
o cranial nerves
o infections
Components of Health History & SOAP Note Documentation
Health History Components:
1. Chief Complaint (CC):
o Reason for the patient’s visit in their own words.
2. History of Present Illness (HPI):
o Detailed description of the symptoms or concerns that brought the patient in.
o Use of OLD CARTS to guide the history (Onset, Location, Duration,
Characteristics, Aggravating/Alleviating factors, Radiation, Timing, Severity).
3. Past Medical History (PMH):
o Chronic illnesses (e.g., diabetes, hypertension).
o Hospitalizations, surgeries, allergies, immunizations, etc.
4. Medications:
o List of current prescription and over-the-counter drugs, including dosage and
frequency.
5. Family History (FH):
o Health conditions of immediate family members, such as heart disease, cancer,
and diabetes.
6. Social History (SH):
o Smoking, alcohol use, substance use, sexual history, occupation, living
arrangements, diet, exercise, etc.
7. Review of Systems (ROS):
o Systematic inquiry into each body system (e.g., cardiovascular, respiratory,
gastrointestinal) for symptoms not directly related to the presenting complaint.
, SOAP Note Documentation:
1. Subjective (S):
o Includes CC, HPI, PMH, medications, SH, FH, and ROS.
2. Objective (O):
o Physical examination findings (e.g., vital signs, auscultation, palpation).
Study Guide | Latest Actual verified study set
complete Solutions | 2026 Updates | 100% Pass
Guarantee
Exam 1 Guide
- Components of health history and SOAP note documentation
- Skin – different lesions, their differential diagnoses and assessment findings
o Common geriatric skin lesions
o Skin Ca
- Eye exam – assessment techniques and findings
o Cranial nerves
- Ears – infection, hearing loss
- Nose/Mouth/Throat – assessment techniques and findings including thyroid and lymph
nodes
o cranial nerves
o infections
Components of Health History & SOAP Note Documentation
Health History Components:
1. Chief Complaint (CC):
o Reason for the patient’s visit in their own words.
2. History of Present Illness (HPI):
o Detailed description of the symptoms or concerns that brought the patient in.
o Use of OLD CARTS to guide the history (Onset, Location, Duration,
Characteristics, Aggravating/Alleviating factors, Radiation, Timing, Severity).
3. Past Medical History (PMH):
o Chronic illnesses (e.g., diabetes, hypertension).
o Hospitalizations, surgeries, allergies, immunizations, etc.
4. Medications:
o List of current prescription and over-the-counter drugs, including dosage and
frequency.
5. Family History (FH):
o Health conditions of immediate family members, such as heart disease, cancer,
and diabetes.
6. Social History (SH):
o Smoking, alcohol use, substance use, sexual history, occupation, living
arrangements, diet, exercise, etc.
7. Review of Systems (ROS):
o Systematic inquiry into each body system (e.g., cardiovascular, respiratory,
gastrointestinal) for symptoms not directly related to the presenting complaint.
, SOAP Note Documentation:
1. Subjective (S):
o Includes CC, HPI, PMH, medications, SH, FH, and ROS.
2. Objective (O):
o Physical examination findings (e.g., vital signs, auscultation, palpation).
